Complaint·June 19, 2025

DPOA instructed staff to monitor R1 and if the pain worsens to give Tylenol and then if needed, the DPOA would take R1 to the hospital in the morning. On 8/21/24 at 7:00am, R1 had an unwitnessed fall in the dining room where R1 slipped out of a chair while sitting down to eat breakfast. Staff were in dining room and assisted R1 off the floor. According to records reviews, this type of fall of slipping out of a bed or chair was not uncommon for R1, however this time R1 complained of pain and was not able to bear weight without assistance. R1’s DPOA was onsite at the facility at that time and drove R1 to the hospital. R1 was diagnosed with a closed fractured sacrum and a closed fracture to the left ischium. ER doctor prescribed Tylenol for R1's pain and R1 returned to facility. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff had neglect and lack of supervision that resulted in serious bodily injuries for R1, therefore this allegation is unsubstantiated. It was alleged that the staff did not seek timely medical care for R1. Based on records reviews and interviews, staff called paramedics to transfer R1 to the hospital after the fall on 8/20/24. R1’s DPOA signed a paramedic release form denying transport of R1 by paramedics to the hospital. DPOA then instructed staff to monitor R1 and if the pain worsened, the DPOA would take R1 to the hospital in the morning. DPOA was notified in the morning of 08/21/25 that R1 slipped out of chair while sitting down for breakfast. This type of slipping fall was not uncommon for R1, however this time R1 complained of pain and was not able to bear weight without assistance. Shortly after the incident, the DPOA drove R1 to the hospital emergency room. R1 was diagnosed with a closed fractured sacrum and a closed fracture to the left ischium. The ER doctor prescribed Tylenol for R1's pain and R1 returned to facility. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff did not seek timely medical care for R1. It was alleged that licensee did not provide R1 incontinence care. Records reviews and interviews indicated that R1 was paying $700/month additional to the monthly payment rate since admission to facility on 06/19/24. R1’s Incontinence Care Plan stated that staff would assist R1 with all toileting needs. Facility staff and nurses used a 24-hour charting system that documented toileting. The charting was available for incoming staff to checked at the beginning of shifts. Examples of entries during a shift are: On 07/30/24 staff assisted R1 with toileting, staff changed his clothes, and staff escorted R1 to breakfast at 06:45am. On 08/15/24, resident was awake at 1:28am and staff assisted him to the restroom and back to bed. 08/16/24, R1 urinated on door right after staff had changed resident. Staff changed R1 again and changed bed sheets. Based on record review, there is not substantial evidence to support the allegation that staff did not provide incontinence care, therefore this allegation is unsubstantiated. An exit interview was conducted with Divina Salinas, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Her signature on this form acknowledges receipt of these rights.