Complaint Investigation Report

The Department interviews revealed multiple caregivers, LVNs, Med-Techs, and the Resident Services Director described monitoring practices, ADL assistance, and activity offerings for Resident #1 (R1) Executive Director David Armour explained caregivers do not chart each ADL task; refusals are documented by exception in digitized Progress Notes provided to the Department. The Department records review revealed service plans included ADL assistance, safety supervision, and activity programming; care notes documented monitoring and diet changes after physician orders; the posted monthly activity calendar was observed by LPA on multiple dates. The Department observations revealed R1 was groomed, room was clean, window intact, and activities were occurring per schedule during visits on 07/21/2021 and 10/27/2021.

Regarding the allegation, lack of supervision resulting in resident sustaining severe bruising. The Department interviews and records review revealed staff followed the facility’s fall response procedures when a large bruise was discovered on 07/06/2021: notifying clinical staff (Med-Tech/Resident Services Director), flagging the chart for increased monitoring, and conducting assessments. R1 denied an unwitnessed fall and exhibited full range of motion with no head trauma signs at the time of assessment. Staff increased observation after discovery. Based on evidence, staff acted according to policy.

Regarding the allegation, staff did not notify responsible party of change in condition. The Department records review revealed the responsible party became aware of the bruise during their 07/10/2021 visit and was informed in person at the facility. Pursuant to Title 22, Section 87211(a)(1)(B), a written report to the licensing agency and the responsible person is required within seven (7) days for serious injuries as determined by the attending physician. The bruise did not meet the definition of “serious bodily injury” under Title 22, and there is no regulatory requirement for immediate notification in this case.