Complaint Investigation Report

LPA met with Administrator Jasmine De La Torre and Ventura Manager of Resident Services Dadesii Daniel and reason for the visit was explained. At approximately 9:45 a.m. LPA and QAS conducted a health and safety inspection of the physical plant. At approximately 10:00 a.m. LPA reviewed and obtained pertinent documents and briefly discussed the incident with administrator and manager. On 02/24/2025, R1’s facility and medical records were reviewed by Investigator Miles. The records revealed that R1. On 04/16/2025 at approximately 12:09 p.m., Investigators Jorge Rojas and Philippe Miles attempted to interview Resident #1 (R1) however, due to R1’s mental capacity and unable to verbally communicate, Investigators were unable to interview R1. Investigators interviewed eight (8) staff on 04/16/2025 from approximately 12:19 p.m. to 2:11 p.m. Additional staff interviews were conducted by Investigator Miles on 12/05/2025 at approximately 12:57 p.m. and on 01/08/2026 at approximately 4:06 p.m.

Following is a summary of the investigation:

On either 03/06/2025 or 03/07/2025, facility staff observed R1 to have slight swelling and bruising on left leg (ankle). Resident records reviewed revealed R1 to have a known history of bruising. Based on R1’s Appraisal/Needs and Service Plan, R1 is also prone to bruising due to diagnosis of Osteopenia and the different medications R1 takes. Staff interviews revealed that staff reported the incident to License Vocation Nurse (LVN) Antoinette Hernandez and Nurse Practitioner (NP) Keith Saucervan which provided specific instructions of how to take care of R1’s left leg using the RICE (rest, ice, compression, and elevation) method. The RICE method was conducted “for a week” which the swelling went down, however the bruising started moving up the left leg throughout the week. Staff interviews revealed that R1 was monitored by the facility LVN and NP. Furthermore, staff reported that they followed instructions given by NP Keith Saucervan which was that if R1’s injury/bruising gets worse to take R1 to the hospital. On 03/14/2025, after R1 was evaluated by the facility NP, it was observed that the RICE method was not working and the bruising continued to move up. Therefore, R1 was transported to Community Memorial Hospital by facility staff where it was discovered that R1 had a “spiral tib-fib fracture” that required surgery.

Based on the information gathered, although the allegations may have happened or are valid there is insufficient evidence to support the allegations. Therefore, the allegations “Neglect/Lack of Supervision - Resident sustained an unexplained fracture while in care of facility” and “Staff did not seek timely medical attention for R1’s injury” are deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report and appeal rights provided.