For Allegation 1 – Resident sustained multiple injuries (including rib fractures) while in care. C#1 has a history of falling, and the facility reported it to C#1’s Psychologist, two years before the time of the 3/19/2021 incident, when C#1 reportedly fell and struck the fireplace while getting up from a dining room chair. Despite Doctor’s recommendation that C#1 be seated against a wall and within a staff member’s reach while C1 has meals, in an effort to prevent sudden movements and potential falls, the facility did neither of these things at the time of the incident, resulting in his fall and head injury. The facility caregiver was unable to give a valid reason for why Doctor’s instructions were not followed, other than to say she is new to the facility and was uninformed, but the administrator acknowledged the incident could have been prevented if the strategies were followed. C#1 additionally sustained several other injuries from prior reported falls, but facility records indicate those may have been the result of seizure activity, which was actively being addressed by C#1’s doctors. The ribs fractures might have been prevented, but it cannot be assumed because of C#1 fall and head injury, the rib fracture was a result of the fall also. The facility will implement doctor’s instructions and inform new and seasoned employees of C1’s needs. The interviews and records did not concur with the above allegation.

Allegation 2 – Resident was hit by another resident resulting in hospitalization. The only indication C#1 was assaulted under the facility’s care was when another resident, C#2, bit C#1 arm. The staff member present at the time of the incident did not witness how the incident began, but staff member stated that staff member separated the residents as soon as staff member became aware of what was occurring. Because I uncovered no evidence to prove the facility’s lack of supervision resulted in the bite, the allegation is therefore 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

An exit interview was conducted with Sharon Hopper, Administrator, and a hard copy was provided.

Allegation 1 - Staff did not seek resident timely medical attention. C#1 suffered a head injury after a reported fall on 3/19/2021 but was not assessed at the hospital until 3/22/2021. The facility administrator was aware of the fall the day it occurred, but she decided to not have C#1 medically evaluated until the morning of 3/22/2021 because she was unaware of a change to C#1 behavior. A caregiver informed me that she noticed C#1 displayed unusual behavior (i.e., more subdued, unable to stand) on 3/20/2021. It is evident that this behavior was either not reported to Administrator or not acted upon, and either would reflect a deficiency in the facility’s response to a change in condition. While at the hospital, C#1 was found to have healing rib fractures of unknown chronicity that were not present prior to 3/29/2019, but hospital records suggest at least one such fracture was already healed by 5/09/2019. Because C#1 did not receive medical attention for over 48 hours after his 3/19/2021 head injury, the allegation that the facility neglected C#1 is therefore Substantiated

Allegation 1 - Responsible party was unable to communicate with facility due to full facility voice mailbox. On 07/15/22, Interviews conducted with Administrator and staff agreed that the voice mail for administrator was full at times and could not leave messages. When staff tried to call administrator to inform her that staff was taking C#1 to ER, they could not leave reach her or leave voice mail message. Administrator changed phones after the incident and stated that her voice mail doesn’t get full anymore. She tries to be checking it and clearing it as often as possible. Staff stated that administrators’ new phone doesn’t get full of voice mails anymore, they can leave messages now. LPA called administrator on new phone and was available to leave a message. The interviews conducted do concur with the above allegation.

Allegation 3 - Facility did not follow reporting requirements. On 07/15/21, Interviews with staff agreed that they do not send the reports to CCLD, administrator send the reports to CCLD. They report the incidents to her, and she takes care of it. According to staff, they reported the incident on 03/19/21 to administrator. LPA reviewed incident reports provided to CCLD for reporting dates, the failed to report the incident in a timely manner, the incident was not reported until 03/34/21. Interviews and records review do concur with the above allegation.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview was conducted with Sharon Hopper, Administrator, hard copy was provided along with Appeal Rights.