Complaint Investigation Report

Additionally, based on the interviews conducted with S1, S2, R1, and A1 and facts related to R1's injury sustained at the facility the second allegation of Neglect/Lack of Supervision is also substantiated. Facility staff members and reporting party all acknowledged R1 sustained a fall on 2/21/22. Facility staff members all denied any other falls occurring for R1. On 3/10/22 a home health aid observed bruising and swelling on R1's ankle and R1 was transported to the hospital where she was diagnosed with a broken ankle. The department has determined the bruising and swelling should have been observed in routine care of R1 prior to discovery by home health aid over 1 week after the documented fall.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medication and Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.