complaint·June 30, 2025

Staff interviews conducted, confirmed the bed rails should have been in the up position and the hospital bed was observed to be in the lowered position. Information obtained from staff interviews revealed, if R1s bed were not left in the down position, R1 would not have fallen from their bed. In addition, the bed rails being put in the “up” position would prevent R1 from falling out of the bed, being that R1 would have behaviors that being that included moving around in the bed. A review of medical records dated 02/02/2023 revealed that R1 was diagnosed with an acute left femoral sub capital fracture with superior lateral displacement and varus angulation. R1 was required to have surgery after being admitted to the hospital. Therefore, the allegation of staff neglect resulted in resident sustaining broken femur is substantiated. Staff did not seek medical treatment for resident. According to staff interviews information revealed on 1/28/2023 at around 2:30pm R1 sustained an unwitnessed fall, this was confirmed by staff who responded to R1s room as they had heard someone from the room scream/yell in pain, upon arrival R1 was the only person in the room. A record review was conducted of the End of Shift Reports, these are reports completed by facility staff at the end of their shifts. The reports revealed the following: a written entry note stating “at the beginning of shift med tech received a call from Resident Assistant in Elm unit, R1 was on floor near bed, the med-tech conducted an assessment and indicated there were no visible cuts or bruising, and R1 was not complaining of pain. Additional information from the End of Shift Reports revealed following: dated 01/29/2023, note R1 seemed agitated and was kicking and yelling; on 01/30/2023, R1 was in pain on their left leg when staff attempted to turn R1; on 01/31/2023, R1 was in a lot of pain when attempts were made to turn and change R1, and hospice was notified. A record review of hospice records was conducted and revealed the hospice agency was notified of R’s fall on 02/01/2023 by a non-staff individual. A review of an Unusual Incident Report dated 01/28/2023 revealed during safety checks R1 was found in their room on the floor near the bed and R1 denied any pain at the time. The Unusual Incident Report also indicated there was no apparent injury. A visit from R1s hospice agency was conducted and a request was made to the hospice agency to get x-rays completed. X-ray results revealed a left hip fracture, resulting in R1 being sent out for further medical evaluation on 02/02/23, five (5) days after the injury/incident occurred. Therefore, the allegation of staff did not seek medical treatment for resident is substantiated. Licensee did not notify POA of resident fall. On 1/28/23 during safety checks R1 was found on the floor. It was determined that R1 had an unwitnessed fall. Per a records review conducted an unusual Incident/Injury report dated 1/28/23 sustained documenting that R1 suffered a fall on 1/28/2023, noting that R1s Primary Care Physician (PCP) and Power of Attorney (POA) were notified. Per a further records review revealed that there was an addition Unusual Incident/Injury report dated 2/2/23 stating that CCL, was informed of the incident on 2/8/23, Primary Care Physician 2/2/23, Placement agency (hospice) on 2/2/23 and R1s responsible party on 2/2/23. Per an interview with previous Residential Services Director Melissa Polendo who allegedly informed R1s POA and PCP of the incident, however Melissa stated that she was not the one that directly notified R1s POA and PCP, but the Medication Technician/Staff #1 (S1) was the one that did. Per an interview with S1 whom stated they informed their supervisors via text message. A further records review revealed that S1 was written up for not following up to ensure the supervisors were properly notified of the incident. Per an interview with R1s POA denied being contacted by facility staff regarding R1s fall on 1/28/23. The department is noted to have been notified of the incident on 2/8/23 however, there was no confirmation of the report being submitted/received. The Unusual Incident/Injury report dated 1/28/23 and 2/8/23 were not signed by the Executive Director nor was there a fax confirmation accompanying the reports. Based on interviews and records review the allegation of licensee did not notify POA of resident fall is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted and a copy of this report, 9099C, 9099D, appeal rights, LIC421IM, and LIC811-Confidential names list was reviewed and provided to Tammy Eddy, Executive Director.