complaint·October 1, 2025

On 3/18/2025 the CCLD RO received an additional complaint regarding R1’s care at the facility with the control number 29-AS-20250318102817. Investigator Jaurequi investigated allegations of both complaints during the investigation. On 03/17/2025, from 11:50am to 1:30pm, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced initial complaint investigation visit to the facility. LPA Haner-Tomasko met with Administrator Carl Meyer and explained the reason for the visit. During the visit, the LPA requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings. Investigator Jauregui conducted interviews; on 04/09/2025, at approximately 2:05pm, with the resident representative for R1; on 04/15/2025, from approximately 9:50am to 1:58pm, with the facility Administrator Carl Meyer, staff and residents; at approximately 3:37pm, with Person #1; on 04/18/2025, at approximately 8:15am, with a former staff; on 04/22/2025, at approximately 3:19pm with another former staff; on 07/25/2025, at approximately 8:32am, with Person #2 (P2); on 08/05/2025 and 08/14/2025, additional interviews with Administrator Carl Meyer; and on 08/11/2025, at approximately 1:13pm, an additional interview with former staff. In addition, Investigator Jauregui reviewed medical records from Twin Cities Community Hospital (TCCH), the County of San Luis Obispo, and facility file documents related to the investigation. On 3/17/2025 and 7/23/2025, LPA Haner-Tomasko interviewed additional staff and the administrator. On the allegation: Due to lack of supervision, resident has fallen multiple times resulting in injuries. LPA reviewed documents including R1’s physician’s report, pre-admission appraisal, service plan, and incident reports. R1’s physician’s report dated 03/12/2024 indicates R1 was diagnosed with rhabdomyolysis, dementia, hyperlipidemia, anxiety, anemia, and history of falling. R1 was considered nonambulatory, had a visual impairment, required continuous bed care, was confused/disoriented at times, required assistance with bathing, dressing, grooming, and toileting. A pre-admission appraisal dated 3/7/2025 indicates the resident uses a wheelchair for mobility. Interviews revealed R1 got around the facility in their wheelchair . (Continued on LIC9099-C) A service plan dated 1/27/2025 indicates R1 required standby assistance from staff to bath, dress, groom, transfer and needed frequent help due to disorientation, memory loss, and difficulty completing tasks. The investigation revealed that R1 sustained falls and incidents on the following dates: on 06/08/2024, at approximately 5:17pm, R1 suffered an unwitnessed fall, R1 had a bump and bruising on their forehead, Emergency Medical Services (EMS) was called, and R1 was taken to TCCH. TCCH records reveal R1 was discharged back to the facility on the same day with a diagnosis of closed head injury; on 12/09/2025, at approximately 9:15pm, R1 was found on the floor, EMS was called and R1 was not transported to the hospital; on 12/15/2024, at approximately 7:00am, R1 slipped off their bed, no injuries were observed. EMS was not called; on 12/24/2024, at approximately 2:27pm, while in the hallway staff witnessed R1 lean forward in their wheelchair and fall headfirst, R1 sustained a knot to the left side of their forehead and discoloration to their left eye, EMS was called, and R1 was transported to TCCH. TCCH records reveal R1 was discharged back to the facility on the same day with a diagnosis of forehead contusion and traumatic hematoma of forehead; on 01/01/2025, at approximately 8:00pm, R1 was found by facility staff on their knees next to their bed, EMS was called, and no new visible injuries were observed; on 01/09/2025, at approximately 7:00am, R1 was found by staff on the floor of their bedroom, EMS was called, and no transport to the hospital was needed; on 02/05/2025, at approximately 8:30pm, R1 slipped off their bed and fell to the floor, staff placed R1 in their wheelchair, staff did not see redness or bruising, R1 did not complain of pain, and EMS was not called; on 02/07/2025, at approximately 7:00am, R1 was found by staff with the top half of their body on the floor and their legs on the bed, R1 complained of pain, EMS was called, R1 was transported to TCCH, and R1 returned to the facility at approximately 11:26am. TCCH records reveal R1 has a discharge diagnosis of UTI and fall. Later the same day at 8:30pm R1 slipped off her bed, staff placed R1 in their wheelchair, R1 did not complain of pain, and EMS was not called; on 03/01/2025, at approximately 5:40am, R1 attempted to get out of their wheelchair and fell, R1 complained of pain in their right shoulder, EMS was called, and R1 was transported to TCCH. TCCH notes reveal R1 was diagnosed with a right humeral neck fracture, a distal radial fracture and ulnar styloid fracture of the right wrist. Overall, R1 sustained ten witnessed and unwitnessed falls in nine months. Records obtained do not indicate R1’s service plan was updated after the first six falls and was only updated on 1/27/2025. The service plan dated 1/27/2025 does not indicate R1 is a fall-risk, does not use an assistive device to get around the facility, and did not discuss any fall mitigation plan despite the numerous falls. (Continued on 9099-C) Multiple interviews revealed the facility often operated short-staffed and it was very challenging to provide the required supervision and care to the residents. Staff stated three caregivers in memory care seemed sufficient, but when there were less they could not meet the resident’s needs. The facility staff timesheets from June 2024 to March 2025, are missing numerous dates, and indicated the facility worked understaffed on multiple occasions including dates R1 fell on 6/8/2024, 12/24/2025, and 2/7/2025. Multiple staff stated there was not a plan to help prevent R1 from falling again, but multiple staff independently attempted to keep R1 from falling as R1 had additional falls. A former staff stated the plan to prevent R1 from suffering further falls was for staff to conduct checks more often, but admitted there was no way to confirm if the staff conducted these checks accordingly. R1’s responsible party raised concerned to facility Administrator on multiple occasions that the facility was understaffed however no changes were implemented. Administrator Carl Meyer stated to the Investigator he was not aware of the facilities staff-to-resident ratio, but denied the facility was understaffed. The administrator admitted R1 had a history of suffering falls at the facility approximating five falls and it was challenging to accommodate R1’s responsible parties requests to implement safety interventions, including additional staffing. Carl explained the plan to prevent R1 from further falls was for staff to conduct “constant supervision.” Carl stated administration did not have a way of ensuring the staff conducted regular checks on R1, and he trusted his staff to perform their tasks efficiently. Carl admitted some of the staff did not perform well and were terminated from the facility. Carl acknowledged the facility had to improve their “quality of service”, fill vacant shifts and was implementing an electronic staff log system to ensure the residents are checked accordingly and timely. Carl could not think of a way to prevent R1’s falls and stated they were going to continue occurring due to R1’s mental status. Carl explained the memory care staff were notified multiple times of R1’s tendency to stand up or lean forward from their wheelchair during staff meetings. Carl stated there is no way to prevent a resident from falling, such as R1, unless they have a one-on-one 24-hour care, which was never implemented. Based on the information obtained, the facility did not appropriately update R1’s physician’s report or service plan after R1 experienced changes in condition on multiple occasions. R1 sustained multiple falls, including one resulting in an injury of a bump and bruising to their face/closed head injury, one resulting in forehead contusion and traumatic hematoma. (Continued on LIC9099-C) R1’s physician report upon admission dated 3/12/2024 states R1 had a history of falling, but the facilities service plan for R1 was never updated to indicate their fall-risk. It has been determined that R1 sustained multiple falls and injuries while in care. No evidence was obtained to indicate the facility attempted to meet R1’s needs by mitigating R1’s falls. Ultimately staff neglect/lack of supervision resulted in a right humeral neck fracture, a distal radial fracture and ulnar styloid fracture of the right wrist. Based on the information obtained, the allegation is deemed substantiated at this time. A $500 immediate civil penalty for injury of a resident as the result of a deficiency is assessed today. The administrator was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49(f). Exit interview, deficiency cited on LIC9099-D, a civil penalty assessed on the attached LIC421IM, report signed, report and appeal rights provided to the Administrator. LPA noted staff interviews revealed there have been occasions where an item from the menu was not sent from the kitchen to the memory care unit, staff reminded the kitchen, and the kitchen staff brought the item. Interviews also revealed the kitchen will sometimes provide a substitute menu item for residents who do not like or cannot eat the primary option. LPA visited the facility nine times between 3/17/2025 and 9/4/2025. During these visits LPA observed and photographed various lunch and dinner meals served to the independent/assisted living unit and memory care during each visit. LPA noted both units being served the same menu items with memory care receiving substitutes or additional proteins on occasion. For example, steamed vegetables instead of salad or chicken/meat in addition to fish. Based on all interviews conducted and LPA observation, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to the Administrator.