Complaint Investigation Report

Regarding the allegation Licensee did not arrange or assist medical care for resident. On 06/19/2021 at 7:30 a.m., staff contacted R1’s responsible party and informed them that R1 had fallen, but did not disclose that R1 had been on the floor all night or that pendant response was delayed. Facility staff did not arrange immediate medical evaluation following the fall. Instead, the responsible party transported R1 to the hospital several hours later, where R1 was admitted with a spinal cord injury. Based on interviews conducted and hospital admission records, the facility did not ensure timely medical care was arranged for R1 after a known fall incident. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Facility did not provide adequate lighting. During the 06/18/2021 blackout, R1’s apartment did not have access to backup lighting. The only available fluorescent light in the bathroom did not illuminate the remainder of the unit. R1 attempted to locate their walker and pendant in complete darkness, resulting in a fall. Staff and supervisory personnel confirmed the facility did not have a generator or battery-operated lighting accessible to residents during the blackout. Facility policy requires ensuring resident safety during emergencies; however, residents were not provided adequate lighting. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Licensee did not follow reporting requirements. Records review and interviews confirmed that the facility did not notify the licensing agency of R1’s fall, extended time on the floor, or hospitalization. Supervisory staff were also not immediately informed of the blackout and fall until contacted by the responsible party. Based on interviews and documentation reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted with facility Executive Director, Wes Lavander, and appeal rights provided.