Facility Evaluation Report

*** THIS IS AN AMENDED REPORT CORRECTING PAGE 2 AT LINE 27 ***

On November 5, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to deliver an investigation finding of an incident that was report by the facility. LPA met with administrator and explained the purpose of today’s visit.

On August 19, 2024, facility report to CCL that on 8/18/2024, resident #1 (R1)’s responsible party reported to the facility that R1 sustained two fractured ribs on the left side of R1’s body and the report indicated that there was an incident that happened on 8/15/2024 involving R1 and staff #1 (S1) may have resulted in R1’s injury.

During the investigation, the Department interviewed residents, facility staff, administrator, responsible party and reviewed documents.

According to R1, S1 told him/her to take a shower and he/she got nervous and punched S1. Subsequently, S1 pushed and hit R1 which resulted R1 fell onto the bed post in R1's bedroom and R1's body hit the bed post.

According to S1, on 8/15/2024, S1 told R1 to get ready for a shower and approximately, 10-15 minutes later, S1 went to check on R1 and R1 turned around and hit S1 and S1 pushed R1 aside to the left that resulted R1 falling at the foot of the bed onto the floor. S1 reported it the incident to staff #2(S2).

According to S2, on 8/15/2024, S1 asked for a pack of ice for R1's hand but never told what actually happened to R1. Subsequently, S1 and S2 went to talk to R1 but did not assess R1. On the next day, when S2 returned to work, S2 did not check on R1's condition.

According to staff #3(S3), on 8/15/2024, he/she observed R1 was in pain when taking a breath, walking and urinating throughout the day but S3 did not report it to anyone.