Complaint Investigation Report

9099C-1.. (R2) was sent to the emergency room on 4/7/25 following the altercation with (R1) for further medical evaluation. Facility charting notes document (R2) returned to the facility on 4/7/25 (4:56 pm) with medication changes and indicate that (R2) had 1:1 care/supervision for the NOC shift of 4/7/25 to 4/8/25, and staff will be doing alert charting and behavioral charting on (R2). Notes further document at 4/9/25 (2:36 pm) that "(R2) took all medications and 1 on 1 care has been with resident all shift", and on 4/9/25 (9:47 pm) that resident has "had no issues out of baseline; med compliant and eaten all meals". Notes state on 4/10/25 (2:28 pm) that "(R2) will continued to be monitored with a 1:1 and resident's behavior/location to continued to be monitored every 30 minutes round the clock".

Staff interviews concluded that (R2) has a history of aggression with staff in the past and has pushed another resident prior to this incident. (R2) also consistently wanders throughout the community and shows exit seeking behaviors. Several staff conveyed in interviews that (R2) should not have been admitted to the facility based on their care needs, as they need specialized care that Citrus Heights Terrace cannot provide.

The Department was told by three different staff that (R2) should have been placed in a higher level of care such as a skilled nursing facility. The facility had to implement 1:1 care for (R2), which is not a service the facility provides and was hiring an outside agency to fulfill the 1:1 care role.

Based on this investigation, the allegation is substantiated that the facility failed to provide adequate care and supervision. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. (R2), who has a known history of aggression towards residents and staff, was not placed on one-on-one (1:1) supervision until following the latest unprovoked assault which resulted in (R1) sustaining a right hip fracture.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page along with a civil penalty for a repeat violation.

An immediate civil penalty in the amount of $500.00 is assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.