Complaint·January 23, 2023

On 1/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady interviewed facility staff regarding the current allegations. Staff 1 (S1) Stated Resident 1 (R1) had incurred a fall at approximately 2 am in the morning on 09/17/2022. R1 was discovered on the floor and assisted back into the bed. According to interview with S1, R1 was attempting to go to the rest room. On 1/17/2023 LPA reviewed documentation sent to R1's physician from the facility. The documentation was a notification that R1 had fallen but had no pain. According to S2, there are no call buttons located in the rooms where R1 was located which was memory care. S2 stated the emergency call button is in the bathrooms. According to interview with S1, and S2, R1 family was contacted approximately 16 hours later, on 9/17/2022 at approximately 2pm because R1 stated there was pain, at which point the family provided the directive to transfer the resident to a medical facility. In regard to Title 22 Regulations, 16 hours is a significant amount of time that the family was not contacted regarding R1 fall and subsequent possible injuries. Therefore, the allegation Facility did not notify resident's responsible party of an incident in a timely manner is substantiated. Based on the Department document reviews including medical file, along with Staff and witness interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. On 1/05/2023 and 1/17/2023 LPA Ivey Canady completed documentation review of materials submitted to the Regional Office by the department. According to medical documentation review, R1 sustained a displaced intertrochanteric fracture of the left femur. According to medical documentation the cause of the injury was an unwitnessed fall that occurred at the facility on 9/17/2022. Based on further review of medical documentation a fracture of the right rib was also discovered from the hospital’s x-ray. The Department noted the right rib fracture was present in medical documentation prior to R1 being admitted to the facility. However, based on medical documentation, the fracture to the left femur occurred at the facility on 9/17/2022. Therefore, the allegation Resident sustained a fracture while in care is SUBSTANTIATED. Based on the Department document reviews and LPA medical file reviews along with Staff and witness interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Page 2 of 3 Cont on 9099-C This entry has been deleted due to approved amendment.