317000237-12-3-2024-59-AS-KHOS-DCFSZE-20241230131900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317000237
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:12:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2024 and conducted by Evaluator Todd Tryon

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240605153211

FACILITY NAME:	OAKWOOD VILLAGE, INC.		FACILITY NUMBER:	317000237
ADMINISTRATOR:	CATHY DUSTIN		FACILITY TYPE:	740
ADDRESS:	3388 BELL ROAD		TELEPHONE:	(530) 889-8122
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	124	CENSUS: 54	DATE:	12/03/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Patty Uclarey, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained unexplained fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Todd Tryon visited the facility unannounced on 12/3/24 to deliver the findings of the investigation completed by the Department. The Department concluded that on June 1, 2024, at approximately 9:30 PM, Med-Tech S2 completed their shift after ensuring R1’s bed alarm was activated, a standard procedure given R1’s fall risk. At 11:30 PM, S1 discovered R1 on the floor during a routine room check but did not recall hearing the bed alarm. S1, who lacks medical training, assisted R1 to bed without informing any Med-Tech, administrative personnel, or family, as required by facility policy. According to the administrator, any unwitnessed fall must result in an immediate call to AMR, and notifications to Med-Tech staff, administration, and family members. R1’s family had, in coordination with the facility, implemented a care plan involving a bed alarm to prevent falls. However, on June 1, 2024, this bed alarm was apparently not working or was not turned on, potentially leading to R1’s undetected attempt to leave the bed, resulting in the fall. The findings show that staff failed to verify the alarm was activated as required by the care plan, resulting in R1’s injury. Based on interviews, Med-Tech S2 confirmed the alarm was turned on at shift end. Based on S1’s interview, S1 indicated that the bed alarm was not functioning as intended and that no medical

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240605153211

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKWOOD VILLAGE, INC.	FACILITY NUMBER: 317000237
	VISIT DATE: 12/03/2024

NARRATIVE

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evaluation followed the incident. Based on an interview with S1, the caregiver involved, S1 confirmed awareness of the fall policy during their interview but did not act in accordance with it. Based on documentation reviewed, it showed that R1 was identified as a high fall risk. R1’s care plan, a joint agreement between R1’s family and the facility, included the consistent use of a bed alarm to prevent unassisted movement that could lead to falls. S2 confirmed activating the alarm before their shift ended at 9:30 PM. However, at 11:30 PM, S1 found R1 on the floor with no alarm sounding, suggesting the alarm was either turned off or malfunctioning at the time of the fall. Failure to ensure the alarm was functioning compromised R1’s safety, as it prevented prompt staff response. Based on records reviewed, the facility protocol for unwitnessed falls and need for immediate notification. Care Plan Documentation: Care plan agreement between R1’s family and facility specified the use of alarms to mitigate R1’s fall risk. On June 1, 2024, at approximately 11:30 PM, R1 was found on the floor by S1, who assisted R1 back into bed without a medical evaluation or consultation with any staff members. S1 failed to report the incident as a fall due to personal judgment. On June 2, 2024, at approximately 6:30 AM, staff observed R1 exhibiting signs of pain during their morning routine and transfers. By 3:30 PM, after a noticeable decline in R1’s condition—symptoms including swelling of the left hip, pale skin, increased confusion, and a skin tear on the left elbow—R1 was transported to the hospital. R1 was sent to the hospital nine hours after pain was first reported. Medical evaluation at the hospital revealed a displaced comminuted basicervical femoral neck fracture and osteoarthritis of the hip. R1 passed away on June 16, 2024, with the primary cause of death identified as the femoral neck fracture and fall. Any report of pain following a potential fall should prompt immediate evaluation by Med-Tech staff, but R1 did not receive this evaluation. Staff interviews confirmed that R1’s condition worsened throughout the day, and only then was hospitalization sought. Based on records reviewed, R1’s fall (6/1/2024) to hospitalization (6/2/2024) document a gap in medical response. Medical Reports: X-rays from the hospital confirmed R1’s femoral neck fracture. Interviews: Staff accounts confirm R1 reported pain throughout the morning without escalation to Med-Tech or administration. Death Certificate: Cause of death includes factors directly related to the fall and delay in medical care. Facility Policy per administrator notes the facility policy mandates that any unwitnessed fall requires immediate medical assessment, which S1 did not pursue. The facility’s failure to properly train and instruct staff on reporting and responding to falls contributed to a delay in essential medical care for R1. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240605153211

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKWOOD VILLAGE, INC.	FACILITY NUMBER: 317000237
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/04/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. .. changes such as ... physical health cond. are observed...changes are documented and	1 2 3 4 5 6 7	The facility will ensure that all care staff are properly trained on policy and procedure regarding falls and follow-up medical attention. Plan for training staff will be submitted to CCL by 12/4/2024..
	8 9 10 11 12 13 14	brought to the attention of the resident's physician and the resident's responsible person, if any. Based on interviews conducted and documentation reviewed. this requirement is not met as evidenced by: It is the documented policy of the facility, that if a resident has an unwitnessed fall, staff is to immediately contact emergency services to evaluate the resident. The Dept. determined that the facility's policywas not followed.Staff assisted the resident back to bed without first notifying Med Tech, Admin. Personnel, or family, as required by facility policy. Records and interviews indicate Resident began to show signs of pain after approximately 7 hours after the fall, but medical attention was not sought until approximately 9 hours after the first symptoms of pain were noted.	8 9 10 11 12 13 14	The facility has already done training with care staff regarding falls and follow-up procedures and medical attention. Training was completed on POC complete.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240605153211

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKWOOD VILLAGE, INC.	FACILITY NUMBER: 317000237
	VISIT DATE: 12/03/2024

NARRATIVE

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Appeal rights provided, exit interview conducted.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd Tryon	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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