W1 stated that R1 was held back by her wrists, resulting in injuries to her wrists, chest, and left arm, as well as a lump on her forehead. W1 stated that R1 hit her head on a wall due to being placed in a restraint. During interviews with the LPA, S1 stated that staff intervened to prevent R1 from falling or injuring herself but did not restrain her. S3 added that R1 was agitated and staff stood close to redirect her and block contact, but no forceful restraint was used. S4 stated, “I saw staff guide her away from the table; no one held her down.” S5 stated by phone, “I touched her elbow to guide her; she pulled away quickly and may have bumped herself.”

LPA reviewed the incident report, charting notes, and daily care logs for 04/30/2025. The documentation reflected that R1 became upset, attempted to strike another resident, and was verbally redirected. There was no documentation of physical restraint. During the facility tour, LPA observed R1 in the common area and did not observe any signs of distress.

Allegation: Staff did not notify resident's responsible party of an incident - Unsubstantiated

W1 stated she was not informed of the 04/30/2025 incident or the 05/01/2025 incident and only learned about them afterward. W1 stated that she would have wanted immediate notification of any injury. In the interview with LPA, S2 stated that after the 04/30/2025 incident, she called W1 several times but received no answer and left a message for the next shift to continue follow-up. S4 stated that he heard S2 say on the phone, “No answer — I’ll try again after rounds.” S1 stated that follow-up calls were part of the facility’s procedure and that a care conference was scheduled after the incidents to discuss R1’s care needs.

LPA reviewed the facility communication logs, incident reports, and staff notes and updates for shift changes. The logs documented call attempts to W1’s listed number on both dates, with “no answer” recorded. Review of the incident report submitted to CCL dated 05/15/25 revealed that W1 was notified of the incident.

***CONTINUE ON 9099C***

Allegation: Staff did not seek medical attention for a resident in care - Unsubstantiated

W1 stated that after the 05/01/2025 incident, in which R1 became angry, fell, and hit her face on a wheelchair, and that the facility did not arrange for medical evaluation, so W1 took R1 to urgent care the next day. S1 stated that staff assessed R1 immediately following the incident and found a small red mark on her cheek but no swelling, bleeding, or signs of distress. S5 also added, “She was alert, eating dinner, and talking to staff. We kept an eye on her all evening.” S3 further stated that R1 was monitored for 24 hours following the incident and her vitals remained stable. LPA reviewed R1's discharge summary from Stanford Medicine dated 5/5/25 which revealed that R1's X-rays all came back negative.

LPA reviewed the internal incident report, progress notes, and the facility’s fall protocol. Documentation showed that staff assessed R1 after the occurrence of the incident, recorded their observations, and monitored her condition per facility policy.

This agency has investigated the allegations above. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.