Inspector’s narrative
What the inspector wrote
with staff, residents, and other relevant parties on the following dates: 05/28/2025, 06/25/2025, 06/26/2025, 07/22/2025, 07/31/2025, 08/01/2025, 08/18/2025, 09/23/2025, 09/24/2025, and 09/25/2025.
Investigator Real also reviewed copies of R1’s medical records, including but not limited to facility medical documents, physician’s documents and outside medical provider records. LPA then reviewed all information obtained by Investigator Real. The following was then determined:
Allegation “Neglect/Lack of supervision: facility employees failed to provide an appropriate level of supervision resulting in R1 falling multiple times and sustaining a fracture:”
The complaint alleges that R1 fell multiple times while at the facility which resulted in R1 sustaining a hip fracture. Interviews and documents reviewed revealed that R1 moved into the facility on 05/19/2023, had a diagnosis of dementia, and was ambulatory at that time. Staff interviewed stated that R1 was very active and walked around the facility’s Memory Care unit often. Incident reports reviewed revealed that R1 had an unwitnessed fall on 08/25/2024 and the fall resulted in no injury. Although no incident report was able to be located, interview and hospital records revealed R1 fell again on 03/04/2025 and was transported to the emergency department for further evaluation. This fall resulted in no injury and R1 returned to the facility the same day. Hospital records and staff interview revealed on 03/08/2025, R1 fell in the common area of the Memory Care unit. R1 was transported to the emergency department, where R1 was diagnosed with a closed comminuted intertrochanteric fracture of the proximal end of the left femur. R1 remained hospitalized for treatment prior to returning to the facility on 03/11/2025. Interview revealed that following R1’s hospitalization, R1 was placed on 15-minute checks, however no documentation was provided to indicate 15-minute checks were completed. Staff interviewed stated the Memory Care unit was understaffed frequently, leaving two (2) caregivers for 20-25 residents with dementia diagnoses. Staff interviews revealed when understaffed, staff were unable to conduct 15-minute checks for the ten (10) residents that required such additional supervision. Staff stated when checks are unable to be completed, the 15-minute check forms were left blank. Incident report and hospital records revealed R1 had another fall on 04/24/2025. Activity staff found R1 on the floor in their room around 05:15PM, R1 appeared to be in pain. R1 was transported to the emergency room, where R1 was diagnosed with an acute periprosthetic fracture (a broken bone that occurs around an orthopedic implant) about the left femoral stem with angulation and an acute
Report Continued on LIC 9099-C (p.3)
right inferior pubic ramus fracture with no right-sided hip fracture. The staff assigned to R1’s care that day had initially been scheduled for Assisted Living but had been asked to work in Memory Care instead due to staff call outs. This staff was unaware they were assigned R1’s care, therefore had not completed any 15-minute checks from 02:00PM until the time R1 was found on the floor around 05:15PM. Interview revealed there were two (2) staff working in Memory Care at the time of R1’s fall. R1 returned to the facility on 05/04/2025. LPAs noted that during the initial visit on 05/20/2025, R1 was not listed on the facility’s 15-minute check list nor the facility’s repositioning list. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “Neglect/Lack of supervision: facility employees failed to provide an appropriate level of supervision resulting in R1 falling multiple times and sustaining a fracture” is deemed SUBSTANTIATED at this time.
Allegation: “Due to neglect, resident sustained a pressure injury:”
Interviews revealed that when R1 moved into the facility, R1 was ambulatory and did not have any pressure injuries at that time, however physician’s report dated 05/19/2023 indicated R1 has a history of skin breakdown with a comment indicating “tailbone.” LPA reviewed documents such as hospital records, facility incident reports, and hospice records for R1. Record review revealed R1 had sustained a broken femur on 03/08/2025 and was bedbound/non-ambulatory following their hospitalization. R1 was then taken to the emergency room on 03/31/2025 for evaluation of a sacral wound. Wound was identified as a stage II at that time. R1 returned to the facility the same day. There was no documentation indicating R1 was admitted to Home Health to assist in caring for the restricted health condition. When R1 returned to the emergency department following their 04/24/2025 fall, hospital notes indicate “seems as if they [facility staff] were unaware that the patient needed to be rotated.” Photographs were taken at the hospital of the wound; however, staging was not provided on hospital documents. On 04/25/2025, hospital notes indicated there was a wound consultation, which identified an open sacrococcygeal pressure injury and stated R1 would be discharged with orders for home health care. By 05/04/2025, R1 had returned to the facility and R1 was admitted to hospice care. Hospice notes from 05/07/2025 identified two (2) wounds on R1 – one (1) sacral wound which was listed as unstageable, and one (1) low buttock wound stage II. On 05/08/2025, Wound Pros visited R1 and resumed wound care. Notes indicated the sacral wound had been present for two (2) months and had increased in size. Staff interviewed stated R1 had a small pressure injury, but this wound was not open until after R1’s second hospital visit. However, facility staff did take R1 to the hospital for
Report Continued on LIC 9099-C (p.4)
wound assessment on 03/31/2025 which was well before R1’s second fall and the wound was identified as stage II at that time. Staff interviewed stated they were unaware of any pressure injuries at that time and therefore did not assist R1 with repositioning or offer assistance in obtaining wound care. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “Neglect/Lack of supervision: Due to neglect, resident sustained a pressure injury” is deemed SUBSTANTIATED at this time.
Allegation “Staff do not serve food of quantity to meet residents’ needs:”
Throughout the course of the investigation, LPA interviewed residents and observed food served. Although some residents felt the food had improved more recently, at the time the complaint was received, residents interviewed felt the portions were too small. Meals are served three (3) times a day, with breakfast served at 07:00AM, lunch at 11:00AM, and dinner is at 04:00PM. Staff indicated snacks are available in the Bistro and the Bistro is stocked by kitchen staff between meals. However, residents stated they need to ask staff when they want a snack and LPAs observed that snacks were not consistently provided. The facility does have two (2) fully stocked vending machines, however, residents are required to purchase these items at an additional cost. LPAs took photos of a sample of some meals served and observed a meal consisting of a small pile of meat, two (2) pieces of cauliflower, two (2) potato wedges, and five (5) baby carrots. Another meal observed contained the following: a ½ piece of salmon, three (3) small pieces of cauliflower, and a slice of sweet potato. According to the United States Department of Agriculture (USDA - fns.usda.gov), an average older adult with a 2,000 calorie diet requires the following daily: two (2) cups of vegetables, five and a half (5 ½) ounces of protein, two (2) cups of fruit, 6 ounces of grains, and three (3) cups of dairy. Food served and menus observed did not contain the appropriate amounts of dairy, fruit, or vegetables on any day reviewed. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation “staff do not serve food of quantity to meet resident needs” is deemed SUBSTANTIATED at this time.
Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) A $1000 Immediate Civil Penalty was assessed. Facility Designees Agnes Gazaryan and Ashley Kumar were informed that additional civil penalties might be assessed based on health and safety code 1569.49(f).
Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.
with staff, residents, and other relevant parties on the following dates: 05/28/2025, 06/25/2025, 06/26/2025, 07/22/2025, 07/31/2025, 08/01/2025, 08/18/2025, 09/23/2025, 09/24/2025, and 09/25/2025. Investigator Real also reviewed copies of R1’s medical records, including but not limited to facility medical documents, physician’s documents and outside medical provider records. Throughout the course of the investigation, LPAs also conducted resident and staff interviews and made observations related to this complaint during various unrelated visits at the facility. LPA reviewed all information obtained. The following was then determined:
Allegation "Staff do not change resident's diapers/clothes timely:"
LPAs observed residents and interviewed staff and residents related to this complaint allegation. During all facility visits, residents in the Memory Care, including R1, appeared to have relatively clean clothing. Staff stated residents are dressed every morning and clothing is changed throughout the day if soiled or dirtied during the shift. LPAs observed laundry hampers in each resident room for resident's dirty clothing. Laundry is washed weekly by facility staff. Staff interviewed stated they provide incontinence care every two (2) hours or more frequently if needed to keep the residents clean and dry. As some residents urinate more frequently than others, their needs may vary. Residents interviewed felt their incontinence needs are being met. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff do not change resident's diapers/clothes timely” is deemed UNSUBSTANTIATED at this time.
Allegation "Staff did not ensure resident's nail hygiene was met:"
The complaint alleges that in May of 2023, R1's family requested their nails be cut during the podiatrist's next monthly visit, however, it was discovered on 04/09/2025 that R1 has what "appears to be roughly 2 years of unattended nail growth." R1's toenails were cut on 04/18/2025. Facility staff interviewed stated the facility does have a podiatrist who visits the facility regularly and the facility provides a sign up sheet for those residents who are interested in using the outside service. Administrator stated that the podiatrist does require payment up front for those residents whose insurance does not cover the service fee. In the case of R1, there is a fee for this third-party service and the fee needs to be paid before service is provided. This was explained
Report Continued on LIC 9099-C (p. 9)
to R1's family. Based on the third-party podiatrist's policy, even if services were requested, if payment was not provided, the podiatrist would not provide service to R1. It is unclear whether services were requested at any time between May 2023 and 04/09/2025. All parties interviewed did agree that once services were requested and paid for on 04/09/2025, R1's toenails were cut on 04/18/2025. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure resident's nail hygiene was met” is deemed UNSUBSTANTIATED at this time.
No citations issued related to the above allegations. Exit interview conducted. A copy of today's report was provided.
