Complaint Investigation Report

Staff called 911, and Resident 1 was transported to Sharp Hospital, where medical records confirmed an acute left femoral neck fracture. LPA interviewed Dr. Randall Baldassarre from Sharp Hospital. Dr. Baldassarre stated that the term “acute” refers to an injury occurring within a few days, and confirmed the injury was consistent with a fall. Although other causes could not be ruled out entirely, Dr. Baldassarre stated that a fall was the most likely cause, especially for an elderly individual. The investigation revealed that Resident 1's care plan listed him as one-person assist, but staff had determined after move-in that he required two-person assistance. The facility did not update the care plan accordingly and failed to take corrective action to ensure Resident 1's needs were met. The facility also did not terminate residency or relocate the resident to a higher-level-of-care setting, despite knowing it could not meet his supervision and transfer requirements. Based on interviews, record review, and corroborating documentation, the preponderance of evidence shows that the facility failed to provide adequate care and supervision. This failure resulted in a fall causing serious bodily injury. 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 Administrator Adrian Guillen, and appeal rights