Regarding Allegation #1: this investigation revealed that Resident #1 was admitted to the facility on February 19, 2022 as a fall risk due to his medical condition and required close supervision. Interviews with staff members and witnesses corroborated that Resident #1 had multiple witnessed and unwitnessed falls that were reported and unreported. Staff interviews revealed that some of these falls resulted in lacerations, skin tears, and bruising. Interviews revealed that Resident #1’s unpredictable, uncontrollable spasms contributed to most of the resident’s falls. On July 21, 2022, Sasaki was found in their room approximately 0830 hours with a nasal injury and was taken to the hospital. Resident #1 was diagnosed with a nasal bone fracture. Staff interviews revealed conflicting information on the resident’s routine checks; some reported 30 minutes and others stated every two (2) hours. Although the facility provided fall interventions; such as, a fall mat, bedrails, and supervision during the day, Resident #1 continued to have multiple falls and some resulted in minor injuries. Interviews with witnesses and facility staff confirmed that Resident #1 required a higher level of care, preferably a bed-alarm or a one-on-one caregiver to monitor the resident on a constant basis to

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained a fracture while in care is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref. LIC 9099D) and civil penalty assessed.

Regarding Allegation #2: this investigation revealed based on interviews conducted with former and current staff, the majority of former staff corroborated that when Resident #1 first moved in (02/19/22), the resident was able to get out of bed and go to the bathroom and get themselves ready independently and only required minor assistance and supervision. Resident #1 required more assistance and supervision due to being a high fall risk. Although the facility provided fall interventions; such as, a fall mat, half bedrails, and supervision throughout the day, Resident #1 continued to have multiple falls that resulted in minor injuries. Resident #1’s seizures and spasms would cause the resident to bite their tongue hard enough to make it bleed. Witness #3 was conducting morning rounds (approximately 8:00 a.m.) and upon entering the Resident #1’s room had observed dried blood on the resident and on their toilet seat, and the front part of the toilet was covered with dried blood. During Witness #3’s first three weeks of employment at the facility, Resident #1 severed their tongue because of the resident’s spasms. Resident #1 had clenched down on their mouth because it had tightened up and the resident bit down, and their tongue got in the way. LPA/RA reviewed Resident #1’s Physician’s Report (dated 02/19/22) documented: history of falls, needs assistance in capacity for self-care: bathing, dressing/grooming, feeding, and toileting needs. A review of the hospital medical records (dated 04/18/22) under “Fall Risk Observation” documented Resident #1 required frequent visual checks and reminders of safety and awareness – including a fall mat and hospital bed. LPA Antonia Alvizar toured facility’s physical plant during the 24-hour visit on 09/29/22. LPA/RA did not observe documentation regarding frequent visual checks for Resident #1. LPA/RA did not observe Incident Report(s) regarding Resident #1 sustaining an injured lip and/or severed tongue due to a seizure or spasm episode.

Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained injuries while in care is found to be SUBSTANTIATED.

Regarding Allegation #4: this investigation revealed Staff interviews revealed conflicting information on the resident’s routine checks; some reported 30 minutes and others stated every 2 hours. Interviews conducted of witnesses corroborated that although Resident #1 was receiving hospice care, Resident #1 required a one-on-one caregiver due to the resident’s declining condition. Upon discharge from the hospital on 07/21/22, Resident #1 returned to the facility. Facility staff failed to re-evaluate the resident’s appraisal and care plan; as Resident #1 increasingly was declining and falls became more frequent. Resident #1's record reviews suggested that Resident #1’s care plan was not updated to suit the resident’s needs and level of supervision. The last updated Plan of Care/ISP was dated 02/19/22, Observation/Tool-Care Task was dated 02/19/22, and Fall-Risk Observation was dated 04/18/22.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of LEVEL OF CARE: Staff did not properly assess resident’s needs in a timely manner is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation(s) issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Staff #1 (S1: Judy Kamenwa Arreaga, LVN – Director of Health Services).

Regarding Allegation #3: this investigation revealed based on interviews conducted of facility, 7 out of 7 corroborated that the facility did not have an incident that involved Resident #2 attacking Resident #4. Interviews conducted of residents in care, 5 our of 5 corroborated that they had not been attacked by a resident in care nor recall observing an incident involving Resident #2 and Resident #4. LPA/RA reviewed the facility’s incident reports and did not observe any report for this incident that occurred on 09/26/22. LPA/RA toured the facility for health and safety purposes and to observe the residents in care. Resident #2 was not interviewed as the resident no longer resided at the facility as of 10/31/22.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff did not prevent resident from physically assaulting other residents is found to be UNSUBSTANTIATED.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff did not prevent resident from engaging in inappropriate behaviors is found to be UNSUBSTANTIATED.

Regarding Allegation #6: this investigation revealed based on interviews conducted of facility staff, 7 out of 7 corroborated that Resident #5 had a deluxe room that consisted of two (2) adjoining rooms. The resident's power of attorney/family member (Witness #2) purchased a hospital bed for the resident who also had a standard twin bed in their second room. Resident #5's hospital bed was delivered to the facility on 09/29/22 and set up by Staff #5. Interviews conducted of Residents, 5 out of 5 corroborated that they did not have a broken bed. LPA/RA toured the (former) Resident #5's bedroom and observed that the facility also maintains three (3) additional hoyer lifts (photo). LPA/RA reviewed R5's Admissions Agreement (dated 02/26/22), Pre-placement Appraisal (dated 02/26/22), and Physician’s Report (dated 02/17/22). Resident #5 was not interviewed as the resident no longer resided at the facility as of 06/30/23. LPA/RA attempted to interview Witness #2, but to no avail.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Residents bed is broken is found to be UNSUBSTANTIATED.

Regarding Allegation #7: this investigation revealed based on interviews conducted of facility staff, 7 out of 7 did corroborated that they do not feel that the facility is understaffed. The facility partners with an outside staffing agency should a staff member not be able to work. Interviews conducted of residents, 5 out of 5 corroborated that they felt the facility staff are meeting their daily needs. LPA/RA reviewed invoices (dated 07/15/22, 07/31/22, 08/15/22,08/31/22, 09/15/22) from Accent Care for services rendered for personal

Regarding Allegation #8: this investigation revealed based on interviews conducted of facility staff, 7 out of 7 corroborated that the housekeepers continue to maintain the cleanliness of each residents’ room. If a housekeeper should not be able to work, the facility has partnered with an outside agency. LPA/RA reviewed the facility’s Staffing Agreement (dated 09/28/22) partnered with Clipboard Health to supply housekeepers. Interviews conducted of Resident, 5 out of 5 corroborated that they have not had issues with their rooms being dirty because the housekeepers do a good job of keeping them clean. Facility staff have not received a complaint from residents or their responsible person that their loved ones’ room is dirty. LPA/RA toured six random rooms and observed the housekeepers conducting their task in the residents’ rooms.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Residents rooms are not being cleaned is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Staff #1 (S1: Judy Kamenwa Arreaga, LVN – Director of Health Services).