Complaint Investigation Report

A review of facility records, including reassessments and internal incident reports, revealed that R1's last annual assessment was completed on August 13, 2024, and identified the need for an increased level of care. Following that assessment, R1 experienced six documented falls on September 15, September 20, September 23, October 1, November 13, and December 6, 2024. Incident reports consistently documented that R1's legs gave out while being transferred by a single staff member.

The investigation further revealed that facility administration, including the Executive Director, Residential Services Director, and other responsible personnel, were aware of R1's significant decline in condition and repeated falls. Despite this knowledge, the facility failed to timely reassess R1, revise the care plan, or implement appropriate interventions, including a documented requirement for two-person assistance during transfers. The facility's failure to reassess R1 and address the resident's increased care needs placed R1's health and safety at immediate risk and contributed to the circumstances that resulted in R1 sustaining a fractured femur.

Therefore, based on interviews, record reviews, the allegation that facility staff neglect resulted in resident #1 sustaining a fracture while in the care, will remain SUBSTANTIATED.

Under Title 22, Division 6, Chapter 8, the following citations are issued and recorded on LIC9099D. In addition, a $500.00 immediate civil penalty is being assessed today due to violation of the Title 22 Regulations posing immediate danger to the resident’s health and safety.

The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Citations issued, appeal rights provided, exit interview conducted and copy of report provided to ED.