Complaint Investigation Report

Regarding Allegation #1: Resident sustained fracture while in care due to staff’s neglect.

It is being alleged that R1 fell and fractured R1 hip due to staff neglect. CCLD staff toured the facility with S1. During tour of the facility CCLD staff noted facility staff helping residents and cleaning the facility. CCLD staff reviewed incident reports (date 07/18/2024, 07/21/2024, 07/22/2024) R1 had 3 unwitnessed falls and staff helped R1 off the floor and called 911. Reviewed needs and service plan (date 07/05/2024), R1 has medical issues but can-do own ADL’s with minimum assistance from staff. Reviewed Physician report (date 07/04/2024), R1 has health issues, ambulatory, no cognitive issues. CCLD staff interviewed S1-S5. 5 out of 5 staff indicate that R1 did not have an unwitnessed fall due to staff neglect. CCLD staff interviewed R1-R3. R1 indicates that R1 did not like using R1 walker. R1 could not recall how R1 fell but indicated the fall occurred at night. R1 indicated that if R1 needed assistance the staff would help R1. 2 out of 2 residents indicate that staff would help R1 after a fall. 2 out of 2 residents indicate that they never witnessed anything concerning at the facility. CCLD staff investigation findings: the interviews of clients/residents revealed they felt safe at the facility and had no concerns with the level of care provided by staff. Therefore, the allegation that R1 sustained a serious injury (hip fracture) due to staff neglect while in care of the facility is Unsubstantiated”.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of “resident sustained fracture while in care due to staff’s neglect” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Mary Montiano S1.