Complaint Investigation Report

S1 went into R1’s bedroom and found blood on the floor and a bloody cracked laundry basket on R1’s bed. S1 accessed R1 and called emergency services. Document review of a special incident report (SIR) dated 8/72023, stated that R2 hit R1 on the head with a laundry basket more than twenty (20) times. Additionally, there were four (4) incidents reported in May of 2023 between R1 and R2. During these incidents, R2 attempted to throw a water bottle at R1, R2 was upset that R1 was in R2’s way, R2 knocked R1’s hat off R1’s head, R1 accused R2 of throwing R1’s walker and hitting R1 on the head. No injuries were reported for the prior incidents. S1 stated that they kept a closer eye on R1 due to believing R1 was at risk. No additional means were made by the facility to ensure the safety of R1.,

For allegation, Resident sustained severe injuries due to staff neglect:

Medical record review of R1’s hospital records from 8/7/2023 revealed R1 sustained severe injuries due to the assault the occurred. R1 suffered from contusions and lacerations of the vertex of the head and the right parietal areas. R1’s wounds went down to the subcutaneous tissue.

Based on evidence obtained during the investigation, the two (2) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because of the preponderance of evidence the standard has been met. In addition, an immediate civil penalty is assessed for $500.00, per Health and Safety Code. In addition, an additional review is being conducted and additional civil penalty may be imposed per Health and Safety Code

During today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed and provided to Facility Caregiver Stephanie Morales, along with a copy of the appeal rights.