complaint·January 29, 2026

[Continued from LIC9099 2 of 3] R1 sustained unwitnessed falls on August 8, 2023, August 9, 2023, and August 12, 2023, the last causing a left femoral fracture. Medical records were obtained from the hospital, and multiple staff members were interviewed. Staff 1 (S1) was interviewed, and S1 reported that the residents, including R1, were being properly checked. Staff 2 (S2) provided contradicting information and made statements to the contrary. According to statements provided by the S3, the nocturnal shift staff have been an issue at the facility, as residents were consistently found to be saturated with urine or soiled, indicating that they were being neglected and not checked on as required. In addition, the proper response time of the falls sustained by R1 appears to have been delayed due to staff not adhering to scheduled safety checks. On September 13, 2023, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in serious bodily injury to a resident, resulting in a pressure injury. R1 sustained a left femoral fracture due to a fall at the facility on August 12, 2023. A review of historical diagnosis, as of September 30, 2023, does not list the pressure sore for R1. August 22, 2023, encounter notes have R1 with a left femoral fracture and have a leg immobilizer on. R1's sacrum and buttocks were reported as being clear with no skin breakdown. R1 was noted as being unable to communicate all their needs and was unable to report the location of their pain. R1 was placed in a splint brace to mobilize their leg for recovery. Written instructions were included with their hospital discharge documents as to the care and monitoring of the splint brace and leg. Statements obtained from interviews with staff tend to show that the splint brace on R1’s leg was not properly monitored or adjusted as instructed on the discharge document. Due to the lack of appropriate monitoring, the splint brace caused a stage III pressure injury on R1's ankle. Medical records documenting the pressure injury were obtained from the hospital. Outside source 1 (OS1) was interviewed, and advised that R1 was susceptible to pressure injuries due to their age and condition. On September 8, 2023, a video encounter notes R1 was brought in on August 12, 2023, for an unwitnessed fall and was found to have a closed non displaced fracture at their left femur. R1 was advised not to bear [Continued on LIC9099] [Continued from LIC9099C 3 of 3] weight for six weeks. Further noted, per Staff 3 (S3), skin is good, no pressure sores. On September 12, 2023, R1 was brought into the Emergency Department after the care facility staff discovered a new left ankle pressure ulcer from wearing their left femoral fracture brace. The emergency Department documented that R1 was brought in and diagnosed with a stage 3 pressure injury on their left ankle. R1 fractured their femur 5 weeks ago and has been wearing a removable brace. A pressure ulcer was discovered today at the facility. S3 reported that they did not take off or adjust the brace until today, when they noticed the new pressure injury. Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Jennie Ayersman, Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.