Complaint Investigation Report

On 09/10/2025, the investigation was referred to Community Care Licensing Division’s (CCLD) Program Clinical Consultant (PCC) and assigned to Lorena Kho. PCC Kho reviewed documents including facility files, hospice records, and hospital records.

During today’s visit, LPA Huynh and the ED conducted a physical plant tour at 10:03AM and no immediate concerns were observed. The following was then determined:

Allegation: “Staff did not seek medical attention for resident in a timely manner”

It was reported that Resident #1 (R1) sustained a fall that resulted in wrist fractures, and the facility did not send R1 to the hospital for evaluation. R1’s Physician Report dated 02/27/2025 documented diagnoses of acute chronic diastolic heart failure, shortness of breath, and mild cognitive impairment. R1 was receiving Hospice services for heart failure and treatment for cellulitis in both legs, with secondary diagnoses including muscle weakness and a disorder of bone density and structure. Although disoriented and forgetful, R1 was able to follow instructions and communicate their needs. They required assistance with bathing, grooming, and toileting and ambulated with a cane and walker. Per R1’s Facility Assessment Summary dated 02/05/2025 with an effective date of 05/01/2025, R1 required standby assistance and cues for transfers and was identified as high risk for fractures due to osteopenia.

Hospice visit notes dated 05/06/2025 documented R1 reporting an unwitnessed fall that occurred on the evening of 05/05/2025. Facility Charting Notes also referenced an unwitnessed fall disclosed during a care plan meeting, though no date or time was documented. This fall reportedly caused bruising and swelling to R1’s right shoulder. The Hospice nurse observed that R1 was unable to move their arm and requested a shoulder x-ray, which returned normal. Beginning on 05/07/2025, facility caregivers documented extensive bruising to R1’s right upper arm, shoulder, and upper chest, along with ongoing complaints of pain. Hospice was notified and advised as needed (PRN) medications.