Complaint·February 24, 2022

Based on the information Investigator Douglas obtained through records review and interviews, the allegation “ Neglect/Lack of Supervision - Resident #1 (R1) sustained multiple injuries at the facility” is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Operations Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued. therefore, R1 was not taken to the hospital. On 09/18/2020, R1’s representative took R1 to R1’s primary care physician for a routine visit. At that time, it was discovered that R1 had a fractured femur which was now healing. It was also reported that on 11/18/2020, at approximately 1:30 am, staff discovered R1 sitting in the stairwell of the facility. R1 was observed to have a bump on forehead and bleeding from nose. R1 advised staff R1 fell. It appeared that R1 attempted to walk the stairs with walker. R1 was taken to Community Memorial Hospital ER as a precaution and diagnosed with a nasal bone fracture. On 11/30/2020, R1 was moved to the memory care unit on the first floor of the facility due to the incident in the stairwell. However, it was reported that R1 experienced several additional falls following being moved to memory care. On 02/10/2021, R1 was in the presence of staff who was standing next to R1 at the time of the fall. The staff explained they could not catch R1 in time. R1 was transported to Community Memorial Hospital ER. R1 sustained compression fractures of L1 and L3 as well as 5 broken rib bones due to the fall . During the course of the investigation, Investigator Douglas was made aware of two additional unwitnessed falls by R1 which occurred on 04/15/2021 and 04/21/2021. On 04/15/2021, in the middle of the night, staff discovered R1 sitting on the floor next to bed. R1 did not sustain any injuries. On 04/21/2021, in the middle of the night, R1 was again discovered on the floor in R1’s bedroom. R1 sustained a bump on forehead and was taken to Community Memorial Hospital ER as a precaution. Continued on 9099C complaint investigation was conducted telephonically with Facility Wellness Director, Lidia Padilla. During the visit, LPA conducted a tour of the facility and requested copies of pertinent documents relevant to the investigation. LPA noted further investigation would be conducted by Investigator Douglas. Investigator Douglas conducted interviews with the Facility Wellness Director on 03/11/2021, 04/13/2021, and 06/04/2021; with staff on 04/14/2021 and 06/04/2021; and with R1’s representative on 05/04/2021. Additionally, Investigator Douglas obtained and reviewed copies of facility records, incident reports, and Community Memorial Hospital medical reports related to R1. Information gathered reflected R1 was admitted to the facility on 03/01/2020. Per the Physician’s Report dated 02/14/2020, R1’s primary diagnosis was age related macular degeneration. The secondary diagnosis was listed as Osteoporosis. R1 was listed as having mild cognitive impairment, ambulatory, and able to independently transfer to and from bed. During the course of the investigation, it was revealed that R1 fell at the facility on multiple occasions and sustained injuries as a result. On 08/11/2020, R1 reported to staff that R1 fell a few days prior. The fall was unwitnessed by staff. At the time of R1’s disclosure, staff assessed R1 and observed a bruise on right hip. R1 complained of pain when walking, however, R1 refused medical attention and was not taken to the hospital. R1 was still able to ambulate with assistance of walker. R1’s representative took R1 for X-rays on 08/14/2020, no fractures were noted. On 08/21/2020, R1 was discovered by staff on the floor of R1’s bathroom. R1 informed staff that R1 lost balance and did not complain of pain or discomfort. No injuries or bruises were observed; Continued on 9099C