complaint·March 30, 2026

(Continuation from LIC9099) Administrator reported that the hospital staff reviewing the x-ray elevated their concerns when it was later discovered that prior chest x-rays showed the rib fractures. A records review was conducted of the facility’s Unusual Incident Reports. A report dated 6/29/2025 documented an unwitnessed fall in which R1 was found seated on the floor, at the base of the couch. She was transported to the hospital for evaluation, where it was confirmed that no injuries were sustained. A report dated 7/20/2025 documented that R1 had exhibited signs of pneumonia and was transported to the hospital by their responsible. This incident is the direct subject of the current investigation. Other than these two reports, no additional incidents involving R1 have been reported. Interview with R1 report that R1 slipped off the couch earlier that year but does not recall sustaining any injuries. An interview with R1 and their responsible person report that R1 was in a major car accident in the 1990’s causing R1 to sustain multiple rib fractures. R1 responsible person reports that the prior fracture was still shown in the x-ray, but the area of the fractures is healed. Interview with R1 confirmed that there is no residing pain from the prior rib fractures and does not recall the last time when R1 experienced pain in that area. Attempts to interview Witness #1 (W1) were unsuccessful. Additional information received document “Per provider, radiologist re-reviewed imaging from previous visit and the rib fractures were present at the time, just didn’t get notated. Plan for DC back to Murrieta Gardens”. Based on interviews and records review, the allegation of “staff did not prevent a resident from sustaining a fracture while in care” is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted where this report was discussed and provided to Administrator.