Complaint Investigation Report

Staff were instructed not to provide care to R1 alone and that two staff were required to assist R1 with all his/her ADLs.

On 07/24/2025, R1’s Primary Care Physician (PCP) examined R1 and noted a resolving ecchymosis/edema on R1’s right upper arm. An X-ray was ordered and showed a displaced comminuted proximal right humeral fracture. R1 was treated with an arm sling. During interview, R1’s PCP stated displaced “comminuted” or fragmented bone injuries typically occur due to impact trauma, such as a car crash or a fall “of considerable height” from a “bed or during a shower.” Such injuries are not generally caused by mishandling or pulling of the arm.

Staff interviewed said that an unwitnessed fall would have been unlikely given R1 was immobile and the right side of R1’s bed was against the wall. Staff did not know how R1 sustained a shoulder fracture. Interviewed staff stated that there was no change to R1’s behavior or baseline in the days prior to when the bruise was discovered. Interviewed staff stated R1 always cried when he/she moved, changed, or was in pain due to the contractures of his/her arms and legs.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated.

An immediate civil penalty of $500 is being assessed today for serious bodily injury or death. See LIC421IM for more information.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

Failure to correct the deficiency may result in a civil penalty. At the time of the inspection report on 10/23/2025, Licensee was informed that the incident is under review and future civil penalties may apply based on Health and Safety Code 1569.49.

This report was reviewed with Licensee Jocelyn Real and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT.