complaint·March 23, 2023

LPA Lopez initially met with facility staff who contacted Administrator Herbert Perey and advised him of the visit. The Administrator arrived shortly after the visit began. The LPA conducted an entrance interview explaining the reason for the visit. Beginning at 1:58pm, the LPA conducted a physical plant tour with staff and reviewed facility records. Copies of pertinent records were obtained. The LPA determined further investigation was needed and informed the Administrator that the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Douglas Real was assigned to complete the investigation. Investigator Real conducted interviews on 11/16/2022 with the Licensee/Administrator and staff; on 12/23/2022, with R1’s resident representative; on 12/29/2022, with resident and staff; on 01/06/2023, with residents and staff; on 01/30/2023, with staff; on 01/31/2023, with R1’s resident representative; and on 02/02/2023, with staff. Investigator Real attempted to speak with the complainant on three (3) different occasions, with no response. In addition, the investigator reviewed St. John’s Regional Medical Center medical records and facility file documents related to R1. A review of R1’s hospital medical records, revealed R1 was admitted to St. John’s Regional Medical Center on 10/23/2022 due to left hip pain. R1 was found to have a left femur neck fracture along with a urinary tract infection and dysphagia (trouble swallowing). R1 was noted as having numerous other health conditions including a history of atrial fibrillation, dementia, Parkinson’s disease, hypertension, and hyperlipidemia and R1’s health was declining. R1’s resident representative decided to transition R1 to hospice for comfort care and R1 passed away in the hospital on 11/02/2022. No abuse or neglect concerns were noted in the medical records. The investigation revealed the facility staff discovered a significant change in R1’s condition on the morning of 10/23/2022. R1 was unable to get up and walk on their own which was unusual as R1 ambulated on their own with assistance as their baseline, in addition, staff found bruising on R1’s hip, leg, and forearm which also had a cut. These injuries were discovered around 8:00am. Due to R1’s diagnosis of dementia R1 was unable to express how they sustained the injuries or the extent of their injuries and pain. At 1:00 p.m., R1’s resident representative noticed R1 was in pain and unable to walk which prompted them to take R1 to the hospital were R1 was diagnosed with a fractured left femur. Continued on LIC 9099 - C Multiple factors, including R1’s inability to express how the injuries occurred, the severity of the injuries or lack thereof, of any internal injuries or pain, along with the existence of multiple bruises and R1’s inability to walk, should have prompted the facility to seek timely medical attention, which they did not. The Department’s information and evidence obtained during the investigation sufficiently supports the allegation; therefore, the allegation “Facility staff failed to seek timely medical treatment for Resident #1 (R1)” is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Administrator Herbert Perey 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 deficiency is cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued. The LPA determined further investigation was needed and informed the Administrator that the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Douglas Real was assigned to complete the investigation. A review of R1’s hospital medical records, revealed R1 was admitted to St. John’s Regional Medical Center on 10/23/2022 due to left hip pain. R1 was found to have a left femur neck fracture along with a urinary tract infection and dysphagia (trouble swallowing). R1 was noted as having numerous other health conditions including a history of atrial fibrillation, dementia, Parkinson’s disease, hypertension, and hyperlipidemia and R1’s health was declining. R1’s resident representative decided to transition R1 to hospice for comfort care and R1 passed away in the hospital on 11/02/2022. No abuse or neglect concerns were noted in the medical records. There was no information in the medical records that indicated R1 had a pressure injury. The hospital records noted R1’s skin was warm and dry, no ulcerations. Interviews conducted during the complaint investigation did not indicate R1 suffered from any pressure injuries. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation. Therefore, the allegation “Resident sustained pressure injury while in care” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.