Allegation - Staff neglect resulted in a resident sustaining an injury from multiple falls. This allegation was assigned to Investigation Branch (IB) Investigator, Laura Garcia to assist with the investigation. During the course of the investigation, interviews were conducted, and medical records were obtained from several medical offices. On 4/5/2020, Resident #1 (R1) was transported to the hospital due to an unwitnessed fall in which resident sustained a serious bodily injury to the head. The San Gabriel Valley Medical Center ER report revealed bruising, hemorrhaging, and swelling to the brain with temporarily loss of consciousness noted. R1 was discharged back to the facility on 4/5/2020. A few days after, R1 had additional unwitnessed falls on 4/7/20 and 4/9/20. On 4/7/20, the facility noted only one fall which resident complained of buttocks pain but did not require medical attention. On 4/9/20, R1 had another fall and hit the back of the head resulted with a bump to the head. The hospice agency was notified, and a hospice nurse came to assess resident on the same day.

Investigator Garcia interviewed 10 individuals (Administrator, Staff, Residents, and Residents’ relatives) via tele visits due to the surrounding Coronavirus (COVID-19) pandemic. Six (6) out of ten (10) individuals reported there is neglect/lack of supervision due to a shortage of staffing. They expressed that Staff are usually busy assisting other residents and do not feel there are enough caregivers to supervise or tend to the residents. Staff interviewed acknowledged R1 was a high risk for falls and/or needed a higher level of care. It was determined that Staff failed to meet the resident’s need and provide adequate supervision to prevent additional falls.

Based on interviews and documents, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today along with a citation for repeating the same violation within the 12 months. Refer to LIC 421IM*** The issuance of an additional Civil Penalty is being considered based on health & Safety Code 1569.49(f); If the Department determines serious bodily injury occurred.

Allegation - Facility is over charging for services not being provided. It was alleged that Resident #1 (R1) was being billed for extra services not provided. According to R1’s Care Plan, it was determined that R1 level of care had changed due to multiple falls in 2020 and health decline. Per the Administrator, the added services charge were discussed with the responsible party over the phone. LPA interviewed 4 Staff who stated that R1 had a decline in health in 2020 and needed extra services such as dressing, medication management, and toileting. They observed other staff or assisted R1 themselves, with dressing and toileting needs. 6 out of 8 residents interviewed stated that the facility is providing the services based on their level of care.

Allegation - Staff is not providing appropriate cleaning services for resident. Administrator stated that housekeepers clean the residents’ rooms and do their laundry once a week. LPA interviewed 2 housekeepers who both stated that they have a list of rooms to clean and laundry to wash as part of their daily duties. This include cleaning an average of 5 residents’ rooms, washing and drying the laundry, as well as folding and delivering back to residents’ rooms. If residents request for additional cleaning services, housekeepers will do so without extra charges. 7 out of 8 residents interviewed stated a housekeeper cleans their room and does the laundry once a week. They did not have any concerns in this area.

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.