Complaint Investigation Report

The nurse reported R1’s condition to R1’s son. R1’s son then instructed Administrator to send R1 to the hospital to get checked on 6/5/2023. R1 went to a skilled nursing facility upon discharge from the hospital and did not come back to the facility.

R1 moved to the facility on May 1, 2023 and moved out on June 7, 2023.

A review of email conversations between Administrator and R1's son indicate the Administrator informing R1’s son that R1 does not have any fracture. And that the hand is not swollen. The administrator also states the reason could be that R1 was taking some part of the bed and has broken pots in the room. The Administrator states, “In the future, I will make sure the care staff calls you and update you regarding any decline.”

A review of R1’s medical records and photo provided to CCL indicate R1 sustained bruises on both arms and a cut on the left bicep. During the interview with Administrator and Staff 1 (S1), both state R1 did not incur any fall. Administrator and S1 state R1 probably got the bruises and cut when R1 was exhibiting aggressive behavior such as crawling under the bed, throwing pots and trying to pull down picture frames.

Based on record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors.

Based on LPA interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D.

Exit interview was conducted with Meeran. Appeal Rights was provided.