Complaint·July 2, 2024

Staff stated while passing morning medications, they found R1 on the ground. They assisted R1 back to bed, and R1 did not indicate any pain. Staff indicates they found R1 around 6:30 am to 7:00 am. Around 7:30 am or 7:40 am, staff checked on R1 and saw the arm was swollen and they believed it to be broken. Staff called the administrator. Administrator stated she arrived at the facility around 7:30 am or 8:00 am. Administrator called hospice first, stating “we are not supposed to call 9-1-1 if they are on hospice.” The hospice nurse came and 9-1-1 was called. R1 also experienced another fall from a chair. Manager stated the pad on the chair slipped out and R1 slid forward, and it happened very quickly. R1 hit their head on the floor and 9-1-1 was called. R1 received stitches and returned to the facility. Administrator stated they called hospice, and hospice indicated to call 9-1-1. Administrator stated again this is the procedure when a resident is on hospice. For medical emergencies that are not directly related to a resident’s terminal illness and reason for hospice services, the licensee must call 9-1-1 and seek medical attention for the resident. Based on the information obtained, R1 received untimely medical attention on two occasions, as evidenced by the delay to contact the administrator and/or hospice before calling 9-1-1. Therefore, the allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. Due to technical difficulties, report and Appeal Rights were emailed to Administrator. staff or residents drinking alcohol in the facility. Residents interviewed stated they have never seen staff drinking, and never smelled alcohol. Residents also stated they had never been offered alcohol. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Due to technical difficulties, report and Appeal Rights were emailed to Administrator.