Complaint Investigation Report

"Staff handled resident roughly causing resident to fall" - Community Care Licensing received an Incident Report and SOC341 Report on 02/25/2025. Reports stated that 02/21/2025, facility received a notice from their fall-detection camera system. Reports stated that in the video footage, Staff Member 1 (S1) was seen grabbing R1, was trying to clean them after they used the bathroom, and that R1 was resistant to receiving the care. Reports further stated that R1 was seen falling backward hitting their head against their bedroom furniture, that S1 did not report the fall to Facility Medication Technicians or the Health and Wellness Director (HWD) on duty, and that Staff Member 2 and Staff Member 3 (S2 and S3) conducted a visual assessment of R1.

LPA reviewed the facility video footage from 02/21/2025. LPA observed that R1 was shown to fall backward with force and significantly hit their head on their nightstand while S1 was providing care.

"Facility did not seek timely medical" - Review of R1’s physician orders indicated that R1 was on a blood thinner medication/anticoagulant. Interviews conducted with S2 and S3 confirmed that they reviewed the video footage on 02/21/2025 and conducted a visual assessment of R1. Interviews revealed that S2 and S3 did not send R1 to the hospital for evaluation per facility protocol because they were instructed by the HWD to not send R1 to the hospital unless they exhibited a change in condition. Per interview with Executive Director, facility protocol is to call emergency services when a resident hits their head. Review of facility’s fall policy stated the following: “…Associates will call Emergency Medical Services (911) when: (a) the resident has…received obvious head or significant trauma, (b) if the resident is on anticoagulants and there is a question of head trauma.”

"Facility did not report abuse to responsible party" - Review of SOC-341 report showed that R1's incident occurred on 02/21/2025 and that the report was received by Community Care Licensing (CCL) on 02/25/2025. Welfare and Institutions Code section 15630(b)(1) states the following: "Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse...shall report the known or suspected instance of abuse...within two working days." Interviews conducted with S2 and S3 confirmed that they viewed the video of R1 and S1 on 02/21/2025 and did not report the suspected abuse incident timely per mandated reporting requirements.