complaint·February 12, 2026

On 09/10/2025, the investigation was referred to Community Care Licensing Division’s (CCLD) Program Clinical Consultant (PCC) and assigned to Lorena Kho. PCC Kho reviewed documents including facility files, hospice records, and hospital records. During today’s visit, LPA Huynh and the ED conducted a physical plant tour at 10:03AM and no immediate concerns were observed. The following was then determined: Allegation: “Staff did not seek medical attention for resident in a timely manner” It was reported that Resident #1 (R1) sustained a fall that resulted in wrist fractures, and the facility did not send R1 to the hospital for evaluation. R1’s Physician Report dated 02/27/2025 documented diagnoses of acute chronic diastolic heart failure, shortness of breath, and mild cognitive impairment. R1 was receiving Hospice services for heart failure and treatment for cellulitis in both legs, with secondary diagnoses including muscle weakness and a disorder of bone density and structure. Although disoriented and forgetful, R1 was able to follow instructions and communicate their needs. They required assistance with bathing, grooming, and toileting and ambulated with a cane and walker. Per R1’s Facility Assessment Summary dated 02/05/2025 with an effective date of 05/01/2025, R1 required standby assistance and cues for transfers and was identified as high risk for fractures due to osteopenia. Hospice visit notes dated 05/06/2025 documented R1 reporting an unwitnessed fall that occurred on the evening of 05/05/2025. Facility Charting Notes also referenced an unwitnessed fall disclosed during a care plan meeting, though no date or time was documented. This fall reportedly caused bruising and swelling to R1’s right shoulder. The Hospice nurse observed that R1 was unable to move their arm and requested a shoulder x-ray, which returned normal. Beginning on 05/07/2025, facility caregivers documented extensive bruising to R1’s right upper arm, shoulder, and upper chest, along with ongoing complaints of pain. Hospice was notified and advised as needed (PRN) medications. Report Continued on LIC 9099-C Later on 05/07/2025, R1 sustained a second fall in the evening while attempting to reach for a snack, landing on the floor in a seated position. Over the following days, R1 continued to report severe pain, and staff documented worsening bruising, swelling, and redness. On 05/11/2025, staff noted that R1’s “[right] hand is so swollen and [their] arm is just hanging down [their] recliner, looks like something pulling it down.” On 05/12/2025, staff documented that R1’s “arm is extremely purple and swollen” and that redness remained present on the arm, hip, and legs. On the evening of 05/12/2025, R1 sustained a third unwitnessed fall near the fireplace, resulting in a skin laceration on the right dorsal forearm. First aid was administered, Hospice was notified, and it was further documented that R1 was “in too much pain.” On 05/13/2025, Charting Notes indicated that R1 was “screaming in pain” and refused to allow staff to reposition their hand. A second x-ray was then ordered on the arm, revealing multiple fractures of the distal radius and distal ulna with soft tissue swelling. Later that evening and at the family’s request, R1 was discharged from Hospice and transferred to the hospital for further treatment. Staff interviews revealed that the facility protocol for unwitnessed falls is to notify the med-tech, who then assesses the resident to determine if a hospital transfer is warranted. The med-tech reportedly conducts a skin assessment, evaluates for major injuries, observes range of motion, and provides the resident with verbal cues. Staff stated that emergency services are contacted immediately if the resident is in pain, has limited mobility, grimacing, hits their head, is bleeding, or sustains a skin laceration. If the resident is on Hospice, the facility notifies the Hospice agency and follows their orders. Staff #1 (S1) expressed that R1 should have been transferred to the hospital immediately after the first fall and again after the final fall resulted in a skin laceration; however, the facility followed the Hospice reporting procedures. The ED also expressed uncertainty regarding whether facility protocols were followed prior to new management. Staff reported conducting daily skin checks but were unable to specify what occurred after reporting abnormal findings, and inconsistencies were noted in how staff monitored residents for injuries. Report Continued on LIC 9099-C Based on interviews and record review, R1 experienced three (3) falls and although staff notified Hospice after each incident, R1’s falls were not related to their condition of acute chronic diastolic heart failure. R1 was not sent for medical evaluation after their falls, reports of pain, decline in physical condition, or following the skin laceration they sustained. The preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.