complaint·September 25, 2025

The Department obtained R1's facility records, which indicated they moved into the facility in November of 2023. Their October 2023, Physician’s Report indicated that they were non-ambulatory and required assistance with transfers and bathing, which was to be provided twice per week. Prior to their move-in, they were diagnosed with a cracked vertebra and were considered a high fall risk. They required daily routine checks and escorts with staff, along with using a walker for long distances. According to two staff members (S2 and S3), there were times when R1 did not recall that they needed their assistive device, and would forget to use it when walking. According to a Service Plan dated December 29, 2023, R1 also had a risk of skin breakdown and required daily skin checks in which staff were to look for redness, discoloration, or open areas of the skin. Staff were to provide bathing, which included monitoring for skin issues twice a week. According to the Pre-hospital Patient Record, R1 was also on blood thinner medication. Facility case notes revealed that on November 11, 2023, R1 sustained a witnessed fall within their first week of care, which resulted in a skin tear. According to facility notes, R1 did not complain of pain, and minor first aid was provided. R1’s Responsible Party (RP) was notified on the same day, which was corroborated by RP when interviewed by the Department on April 12, 2024. 10 days after the fall, on November 21, 2023, the facility noted a change in condition, as R1 began to present with discoloration in their leg. No notation was made indicating that R1’s RP or Physician was informed on the day of the observation, nor was medical care obtained. It was noted that the RP was notified more than 24 hours later, which was corroborated during an interview with RP. On November 22, 2023, an Outside Source (OS1) expressed concern regarding the facilities delay as R1 was on blood thinners, which means “she’ll bleed more”. On December 2, 2023, staff annotated R1 had a hematoma on the left side of their hip, however it was also noted that RP was not made aware until one day later, December 3, 2023. In February 2023, R1’s case notes indicated that a staff member [S1] observed them with an unexplained skin tear to the right arm and a bruise on the wrist. It was noted that another staff member was notified, but not R1’s Responsible Party, which was corroborated by RP. [CONTINUED ON LIC9099-C] In March, R1 complained of pain to an Outside Source (OS1), and said that it was because they had fallen. On March 7, 2024, OS1 contacted facility staff (identity unknown), who replied that they conducted a check on R1 and found them in bed. Several days later, another outside source (OS2) visited R1 and observed them crying with pain. When questioned by OS2, staff reported R1’s crying was due to soreness from walking. The Department interviewed staff member #2 (S2), who was present at the time and stated they were aware that R1 had fallen. S2 clarified they reported it to another staff member (S1), and mobile medical care was ordered. According to Mobile Medical Records dated 3/6/23, R1 was seen for severe pain in the hip and groin areas, and 911 and transfer to the hospital were required and activated. However, interviews with OS1 and staff (S1, S2, S3), Ambulance Records, and Hospital Admission records all indicated that 911 was not activated until 4 days later, March 10, 2024, where R1 was diagnosed with a closed fracture of the sacrum and coccyx, and a compression fracture of their vertebra. A review of facility case notes further revealed there were no documented notes regarding R1 from February 20, 2024, to March 9, 2024, which included the dates concurrent with their fall. A further review of Department records revealed that eighteen days later (3/28/2024), the facility reported the incident to the department, eleven (11) days later than required. Over the course of R1’s residency, records indicated the presence of 5 unexplained injuries while in care. Multiple staff members, S1, S2, S3, and a former Executive Director, were aware R1 was a fall risk and needed assistance with escorting daily. The Department interviewed several staff members who were aware of R1’s falls (S1, S2, and S3), including former Memory Care Director and Executive Director, and all reported that no additional interventions were put in place to mitigate the risk of injury or fall. On April 12, 2024, the Department interviewed the Executive Director (ED), Gregory Case who had been responsible for the facility for approximately one month before R1’s final fall. ED was not aware of any modifications or any care plan changes for R1 after their falls. According to multiple staff interviewed (S1, S2 and S3), and the former Memory Care Director, the statements corroborated ED's statement regarding R1’s care plan not being updated after their falls, which included no definitive plan to update R1’s service plan for mitigating their falls. [CONTINUED ON LIC9099-C] Based on the Department’s investigation of the above-mentioned allegations, the evidence obtained during staff and outside source interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard and the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D page of this report. As at least one violation resulted in the injury of a resident, an immediate civil penalty is hereby assessed per Health and Safety Code 1569.49(c)(1) and attached on the LIC421IM. Additional civil penalties are under review by the Department and may be assessed at a later date. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Executive Director Thomas. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit and the signature below confirms the receipt of these documents.