complaint·January 31, 2023

During the visit, the LPA conducted staff and resident interviews, reviewed resident files, obtained pertinent documents, and toured the facility with the Business Office Manager. The LPA determined further investigation was needed prior to issuing findings. On 04/04/2022, at approximately 5:00pm, Investigator Garcia conducted an interview with the Administrator; on 04/12/2022, from approximately 11:00am to 2:00pm, with Administrator, staff and residents; on 08/16/2022, at approximately 9:43am, with R1’s resident representative; on 08/30/2022, from approximately 11:30am to 12:00pm, with staff. On 12/2/22 at 10:00 a.m., investigator Garcia interviewed a resident care coordinator. On 12/7/22, Investigator Garcia spoke with the resident’s physician’s staff and obtained a copy of R1’s medical condition and progress notes. On 1/4/2023, Investigator Garcia interviewed R1’s physician. Additionally, Investigator Garcia requested and reviewed hospital medical records for R1 and facility file documents related to R1 and R2. On 04/19/2022, the Oxnard Police Department informed Investigator Garcia there were no incident reports or service calls for the facility or concerning R1 and R2. Regarding the allegations “Resident was injured while in care’ and ‘Resident sustained multiple unwitnessed falls while in care’, the complainant’s concern was that the facility staff was not adequately supervising R1 and R2, which resulted in the residents’ experiencing multiple falls in addition to sustaining injuries. The investigator found the following during the course of their investigation. Resident #1 (R1) sustained a right orbital fracture from an unwitnessed fall. Interviews were conducted with R1, R1’s representative, facility Administrator, staff, residents and R1’s physician. R1 stated that the morning shift staff observed R1 with blood on their face, and immediately rendered medical aid and dialed 9-1-1. According to R1, the staff acted accordingly to their medical needs and denied having any complaints against the staff. R1’s representative did not have issues regarding the level of care and supervision provided by the facility staff. R1’s physician stated that although R1 was diagnosed with the early stages of dementia and was legally blind, R1 was able to independently move around, accomplish R1’s personal goals while requiring minimal assistance, which was contrary to R1’s physician’s report and resident assessment, which stated that R1 needed one to one assistance for all activities of daily living, with the exception of eating. The facility is in the process of obtaining an updated physician’s report from the physician. Staff indicated that R1 could care for their own activities of daily living with minimal assistance from staff. There was no evidence provided that R1 required a higher level of care or a one-to-one assist. Continued on LIC 9099 - C Resident #2 (R2) was found on the floor with a bruise on their eye and forehead; and, according to R2, the facility staff conducts their supervision rounds every hour. While attempting to move around in R2’s bed, R2 fell out of bed and sustained minor injuries around eye and forehead. R2 confirmed that the staff immediately dialed 9-1-1, and the paramedics rendered medical aid. Due to minor injuries, R2 declined to be transferred to the hospital and staff continued to monitor R2 every half hour. R2 denied having any complaints against the level of care provided by facility staff or issues of neglect or lack of supervision. Based on statements and documentation provided, the Department does not have sufficient evidence to determine that there was negligence or lack of supervision on behalf of the facility staff. Although both R1 and R2 did suffer an injury while at the facility, there is insufficient evidence to conclude that it was due to neglect on the part of facility staff. In addition, although both residents sustained unwitnessed falls while in care, there is insufficient evidence to conclude that the falls were as a result of staff negligence. Therefore, the allegations that ‘Resident was injured while in care’ and ‘Resident sustained multiple unwitnessed falls while in care’ are deemed as unsubstantiated at this time. Exit interview, copy of report was issued.