complaint·April 27, 2022

Continued from LIC9099A When the fall occurred, facility staff were nearby and heard the fall and immediately came to assist R1 by providing first aid. R1 was not able to tell staff the cause of the fall due to having dementia. However, according to staff, R1 was able to get up and did not complaint of any pain. According to interviews with staff and outside parties, R1 did not have a history of falls during the two (2) years they had lived at the facility nor did R1 have a history of falls prior to moving into the facility. Staff indicated that R1 enjoyed walking inside the facility and was able to walk around without a walker or a cane with no problems. Based on the information gathered during the interviews conducted with staff and outside parties and the information obtained from the records reviewed, there was insufficient evidence to indicate that facility staff were neglectful in the supervision of R1 that could have contributed to R1’s fall. It was also alleged that facility staff did not administer medication according to physician's orders. Interviews conducted with staff and outside parties revealed that R1 was taking medication for high blood pressure. During interviews, staff consistently indicated that all medications including the medication to treat high blood pressure were administered to R1 according to physicians’ orders. All medications including the high blood pressure medication were delivered by the pharmacy every month, and the high blood pressure medication was in the “bubble packs” which made it very easy not to miss any doses. Review of R1’s Medication Administration Records indicated that all medications were administered as prescribed, Specifically, staff indicated that because R1 had a history of high blood pressure, they were diligent about giving the medication to R1 every morning as prescribed. The Department has investigated the above-mentioned allegations and has found that based upon interviews and record reviews, there is insufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are deemed to be unsubstantiated. An exit interview was conducted with Administrator, Carina Carmona. A copy of this report, and Licensee Appeal Rights (9058 01/16) were provided to Administrator after the conclusion of the visit. continued from LIC9099 Administrator indicated that they attempted to call to make an appointment with the primary care physician, but when the doctor’s office did not return the call for several weeks, facility staff still did not take R1 to see a doctor. The Administrator said that the reason they did not take R1 to the doctor was because they did not want to expose R1 or the other residents living in the facility to being infected with Covid-19. However, even after they observed the knee getting more swollen day-by-day, the licensee still did not take R1 to see a doctor. According to facility staff, they waited almost four (4) weeks to take R1 to see a doctor. When medical attention was finally provided, it was discovered that R1 had suffered a patellar (knee) fracture that required surgery. Based on the information gathered during the investigation, the Department was able to obtain sufficient evidence to support the allegation that facility staff did not seek timely (emergent) medical attention for R1. According to regulation, the gravity of the injuries R1 sustained warranted the licensee to provide medical attention to include arrangement for and/or provision of transportation to the nearest available medical provider. It was also alleged that staff did not follow reporting requirements when R1 sustained a serious injury due to a fall. During interviews with facility staff, it was indicated that when R1 had the fall on August 1, 2020, sustaining a fractured knee and bruising to the head and eye, facility staff did not report the incident to the Department as required. According to regulation, the licensee shall furnish to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events, including incidents that result in injury. The Administrator admitted they were aware of the regulation but did not have a chance to submit the report as required. It was also alleged that facility staff did not safeguard R1’s personal property. According to interviews with facility staff and outside parties, when R1 moved into the facility they brought a suitcase full of clothes. According to the Administrator, the suitcase was disposed of because it was broken and unusable. However, R1’s responsible party claimed the suitcase was in new condition and in working order and they did not give permission for staff to dispose of the suitcase. Licensee may not dispose of resident’s personal belongings without obtaining prior consent. Continued on LIC9099C Continued from LIC9099C The Department has investigated the above-mentioned allegations and has found that based upon interviews and record reviews, there is sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was developed with Administrator, Carina Carmona. An exit interview was conducted with Administrator, Carina Carmona. A copy of this report, and Licensee Appeal Rights (9058 01/16) were provided to Administrator after the conclusion of the visit.