Complaint·May 30, 2025

(Continue from LIC9099) The complaint specifically alleged that R1 experienced an unwitnessed fall in their room on the night of November 8, 2022. R1’s medical and facility records indicated a diagnosis of unspecified dementia and residence in the facility’s memory care section. According to a physician’s report dated January 19, 2022, R1 was ambulatory and able to communicate needs. Interviews with R1 and outside sources consistently reported that R1 slipped due to water on the floor. After the fall, R1 did not report the incident to staff and was able to get up from the floor unassisted and return to bed. The next morning, R1 complained to the staff of lower back pain and requested pain medication. Staff interviews revealed that R1 denied any fall or injury. Interviews with residents, staff, and outside sources confirmed that several rooms, including R1’s, had ceiling leaks for several days due to broken water pipes. Maintenance had placed buckets and towels under leaks to mitigate hazards. Although staff had placed buckets and towels as a temporary measure, it failed to adequately address the hazard. During interviews, it was confirmed that the wet floor condition contributed to R1’s fall. During a visit conducted on November 21, 2022, the ceiling repairs caused by the water leak in R1’s and other residents’ rooms were confirmed by observation. Additional interviews with staff and residents did not yield any other reported injuries caused by the water leaks. It was also alleged that facility staff did not seek timely medical care for R1 to meet their needs. On November 9, due to persistent back pain, the staff ordered a mobile x-ray, which returned unclear results. Despite ongoing back pain complaints, additional medical evaluation was not pursued until November 11, when R1 disclosed the fall to their responsible party. R1 was then immediately transported by R1’s responsible party to the hospital, where a CT scan confirmed an acute L1 vertebral fracture. R1 was subsequently discharged to a skilled nursing facility for rehabilitation. It was confirmed that R1 recovered and was discharged back to the facility from skilled nursing. Although staff did not receive timely notification of the fall, R1 complained of back pain, and medical attention was delayed until November 11, when a hospital CT scan confirmed the injury. The delay in seeking further medical evaluation despite ongoing pain was deemed inadequate care. (continue at LIC9099C) (Continue from LIC9099C) Based on interviews and records review, sufficient evidence supports the allegation that staff negligence in addressing the slipping hazard directly resulted in R1’s fall and injury. It was also substantiated that facility staff did not seek timely medical care for R1. Although the initial x-ray was unclear, staff should have pursued further evaluation when R1 continued to report acute pain. Timely medical attention is a reasonable expectation to ensure residents' health and safety, especially those with dementia. The Department finds the allegations substantiated, meeting the preponderance of evidence standard was met. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, detailed on LIC 9099-D. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Suuronen-Goodwin. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director Suuronen-Goodwin, who was provided a copy of this report, the Confidential Names List (LIC 811), LIC 9099D Deficiency Report, and the Licensee Appeal Rights (9058 03/22). (continue from LIC9099A) During a follow-up inspection on November 21, 2022, facility temperatures were measured and found to be within the range required by Title 22 regulations, between 74-75 degrees Fahrenheit. Multiple interviews with residents and staff confirmed that the heater had been nonfunctional for four days in November. However, interviewees consistently reported that the facility’s temperature remained comfortable, and no concerns were raised about rooms being too cold. One resident recalled the heater outage but stated that wearing sweaters and using blankets provided sufficient comfort. Staff and residents also reported receiving no formal complaints regarding the facility’s temperature. Based on the investigation’s findings—including observations and interviews with key staff and residents—there was insufficient evidence to substantiate the allegation. Therefore, this allegation is unsubstantiated. An unsubstantiated finding means that although the alleged violation may have occurred, there is not a preponderance of evidence to confirm it. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin at the conclusion of the visit. She was provided with a copy of this report and the Licensee Appeal Rights (9058 03/22).