Facility Evaluation Report

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a substantiated complaint number: 14-AS-20190327094949, regarding an allegation that staff failed to provide care, supervision, and services to meet the needs of Resident 1(R1) resulting in R1 sustaining multiple injuries. LPA met with Administrator, Scott Evans and explained the purpose of the visit.

On November 26, 2019, the Department concluded a complaint investigation and the allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.2(a)(4)” Additional Personal Rights of Residents in Privately Operated Facilities for facility failing to provide care, supervision and services that met R1's needs that resulted in R1 sustaining serious bodily injury.

The investigation revealed that the plan of care for R1 was not individualized to tailor fit R1’s needs. Furthermore, R1’s hospitalization dated January 16, 2018, indicated R1 has a diagnosis of gait disorder and the physical therapist (PT) assessment notes dated March 1, 2018, identified R1 as high-risk for falls. The facility did not reassess the resident to develop a plan of care to meet R1’s needs.

R1 had three separate incidents at the facility. On April 26, 2018, R1 was found on the floor and sustained a large skin tear to the left arm. On August 9, 2018, R1 stood up, fell on the floor, and sustained a fracture to the right hip. R1 was hospitalized and had surgery for a right hip fracture. Per document review and Administrator interview, there was insufficient staffing with only one staff on duty and that staff was assisting another client when R1 had the first two falls.

The third incident was discovered when R1 was noted with back and leg pain on October 4, 2018. R1 continued to report pain during the night and continued to the next day. On October 5, 2018, around 2:00 p.m., R1 was reported to be in severe pain, and staff called R1’s family member and informed them the facility would call an ambulance to transfer R1 to the ER for evaluation. Two hours later at 4:00 p.m., the facility called an ambulance to transfer R1 to the ER. R1 was taken to the ER and R1 was diagnosed with a compression fracture in their back and a left hip fracture. (CONT. TO 809C)