complaint·November 18, 2025

9099C-1.. Allegation: Staff do not provide adequate care and supervision to the residents. The allegation states that on Tuesday (08/05/2025) around dinner time, resident (R1) was escorted to the dining table but managed to wander out of the dining room and into the hall, where (R1) fell and broke their nose in two places, requiring stitches on their lips. The family member stated in August 2025 they are concerned that the residents at the facility aren't getting proper supervision, and staff are not "hands-on enough" to prevent things like this from happening. This family member stated they also have had to lend a hand for (R1) and for other residents when visiting. Two (2) staff interviews conducted on August 19, 2025 revealed that (R1) was running in the hallway earlier in the day on August 5,2025, around 11:00 am, which was unusual behavior for (R1), and this was the first time (R1) was observed to run. The re-assessment (dated July 21, 2025) notes (R1) "will walk around the community very slowly". The administrator explained, on August 19, 2025, that a third staff, who "was not assigned to care for (R1)" let a Med-Tech (S1), working on the "am" shift, know that (R1) was "acting very off" that day, and explained how (R1) was "leaning forward when walking and was very agitated". The administrator indicated that (R1) was "not listening" to staff earlier that day before falling around 4:45 pm. (R1's) re-assessment (July 21, 2025) notes “Staff will observe resident expressions due to UTI’s, will tend to peri care area for cleanliness and report any changes”. The assessment also notes (R1) needs Full assistance with feeding and mealtime support- Staff need to pay attention as some days may need extra help/cueing . The reappraisal also states that (R1) needs "maximum assistance with ongoing strategies to maintain safe and appropriate interactions" and for staff to "provide enhanced interventions and care coordination to de-escalate negative behaviors". The incident report (LIC624) submitted to the Department on August 6, 2025 describes the conditions leading up to (R1) experiencing a fall face down in the hallway on August 5, 2025 (4:45 pm). The LIC624 notes that prior to the fall, (R1) was "observed to be walking at a fast paced around the hallway" and that "care staff approached (R1), but (R1) declined assistance". The report also states that "later during the dining period, the resident was in and out of the north dining room when (R1) accidentally bumped into the door frame of resident room (#), causing (R1) to lose balance and fall face first on the carpeted floor". (R1) sustained a nasal laceration and nasal bone fracture and returned with stitches on their nose". *cont on 9099C-2.. 9099C-2.. Charting notes entered by a Med-Tech staff (S2) who witnessed the fall document that "Resident was seen walking fast paced around the facility- multiple care staff and both Med-Techs tried to get (R1) to have a seat but (R1) got agitated and refused assistance . (R1) walked in and out of north dining room, bumped into the door frame (nearby room), lost balance and fell face first into the carpet". Charting notes entered by the Interim Resident Care Coordinator on August 7, 2025, describe how "prior to the incident, (R1) was observed to be walking at a fast pace around the hallway"; care staff approached (R1) to suggest a seat, but (R1) declined assistance". The notes describe (R1's) agitation just prior to the fall and how (R1) was "in and out of the north dining room when accidentally bumped into the door frame" of a nearby room. The notes also state (R1's) family member was present to take a photo and video of (R1) when the ambulance provider arrived. The administrator stated staff observed a "lot of blood" after (R1) fell, and (R1's) "whole eye area and cheek area were purple", confirming (R1) returned later that day around 9:00 pm with a Urinary Tract Infection (UTI) and 5-day antibiotic". The MAR shows that Amoxicillin 875-125 mg was prescribed to start on August 6, 2025, one tablet every (12) hours for (5) days, until August 10, 2025 and Naproxen 500 mg was prescribed to be given twice per day, on August 7, 2025, as needed for mild pain for (14) days. Additionally, the MAR reflects Aspirin 81 mg was held from August 6, 2025 through August 11, 2025. The Administrator stated on August 19, 2025 that maintenance staff, tried to access the video footage from 8/5/25 (4:45 pm) but was not able to and commented that the video "may not be available after a week". LPA spoke to maintenance staff on this same day who confirmed he was unable to access the video. (R1's) family member stated they will "hold (R1's) hand as (R1) can't see that well" and confirmed they visit (R1) regularly. The physician's report notes (R1) has a visual impairment and does not like to wear their glasses. The care plan notes (R1) needs full assistance with vision care, staff are to assist as individuals living with Dementia may not see from the sides, resident refuses to wear glasses and (R1) "needs to be escorted to meals, hand held and guided". Although the allegation states (R1) was escorted to the dining room prior to the fall on August 5, 2025 (4:45 pm), charting notes made by (2) different staff indicate that (R1) "was in and out of the north dining room, and accidentally bumped into the door frame, causing her to lose balance and fall face first". *cont on 9099C-3. 9099C-3.. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Exit interview. Copy of report and appeal rights provided.