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13 | Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver the investigative findings. LPA met with the Facility Administrator Don Barber and explained the purpose of the visit regarding the allegation of neglect due to lack of care and supervision.
First Allegation: Neglect Lack of care and supervison
On September 26, 2024, the Department received a complaint alleging that facility staff failed to provide resident 1 (R1) with appropriate care and supervision from September 12, 2024, through September 16, 2024. The investigation was conducted by Department staff and included a review of relevant facility records, medical records, incident documentation, and interviews with facility staff and witnesses. The investigation revealed that on September 9, 2024, (R1) sustained an unwitnessed fall at the facility during the day shift. Following the fall, facility staff did not obtain medical evaluation for (R1). On the morning of September 10, 2024, (R1) daughter visited (R1) and observed that (R1) appeared to be in pain and was unable to bear weight on (R1) left foot. |
| Substantiated | Estimated Days of Completion: |
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32 | Due to (R1) condition, (R1) daughter transported (R1) to St. Mary's Hospital for emergency medical evaluation. At St. Mary's Hospital, (R1) was diagnosed with a fracture of the left iliac crest and was subsequently transferred to Hospital for further medical treatment. On September 12, 2024, R#1 was discharged from Hospital and returned to Sterling Inn with hospice services provided by Green Valley Home Health Service (GVHHS). On September 25, 2024, (R1) was hospitalized due to numerous falls. (R1) was diagnosed with a large tumor in the left frontal lobe. Based on a review of medical records, facility records, and witness statements, the Department determined that facility staff failed to provide R1 with appropriate care and supervision following the fall on September 9, 2024. Specifically, the evidence established that R1 sustained an unwitnessed fall and subsequently experienced pain and an inability to bear weight on the affected extremity. Despite these circumstances, facility staff did not obtain timely medical evaluation for R1. (R1) condition was subsequently identified by R1's daughter, who transported R1 to the hospital the following day. Medical evaluation resulted in a diagnosis of a left iliac crest fracture.
Second Allegation: Facility did not address Resident as being a fall risk.
The investigation was conducted by Department staff and included a review of relevant facility records, medical records, incident documentation, and interviews with facility staff and witnesses. The investigation revealed that In July 2024, R1 initially began residing in the facility’s Independent Living area. Facility records indicated that R1 was ambulatory and able to walk independently. R1’s initial care plan indicated that R1 was independent and did not require assistance with care. On September 16, 2024, R1 was reassessed following multiple falls sustained during September 2024. The assessment documented that R1 had been slipping and falling out of their chair and bed. However, the falls that occurred on September 9, 2024, were not appropriately addressed. Staff interviews revealed that staff were unable to determine the cause of R1’s repeated falls. Staff further reported that R1 sustained multiple falls without apparent injuries before R1’s daughter took R1 to the hospital on September 25, 2024, which diagnosed R1 with a large tumor in the left frontal lobe. Despite the recurring falls, facility staff failed to take timely preventive measures to reassess R1’s condition and identify the increased risk of falling. The evidence further established that facility staff did not complete an Incident Report following R1’s fall on September 9, 2024. Additionally, the facility failed to report the incident to Community Care Licensing (CCL). Based on the preponderance of evidence obtained the department has found that the above allegations are substantiated. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/30/2026
Section Cited
CCR
87465(2) | 1
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7 | Incidental Medical and Dental Care 87465 (2)....The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
This requirement is not met as evidence by: | 1
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7 | The Licensee has agreed to review Title 22 Regulation 87465(2), Incidental Medical and Dental Care, to ensure compliance with applicable licensing requirements. The Licensee will also ensure that staff receive training facilitated by a licensed professional regarding the regulation and its requirements. Documentation of the training will be maintained and provided as proof of compliance. The documentation will include the facilitator’s name, professional license credentials and license number, staff signatures acknowledging completion of the training, and the date the training was completed.
The Licensee will ensure that staff understand and follow the requirements of the regulation to promote the health, safety, and well-being of residents.
Date of Completion: 10/30/2026
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14 | Based on interviews, and record review, the licensee did not adhere to the regulation stated above and did not provide R1 with proper medical assistance, which poses an immediate health, safety, or personal rights risk to residents in care. | 8
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Type A
10/30/2026
Section Cited
CCR
87411(a) | 1
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7 | Personnel Requirements – General 87411 (a)…. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidence by: | 1
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7 | The Licensee has agreed to review Title 22 Regulation 87411(a), Personnel Requirements – General, to ensure compliance with applicable licensing requirements. The Licensee will ensure that all staff receive training facilitated by a licensed professional regarding the regulation and its requirements.
Documentation of the training will be maintained and provided as proof of compliance. The documentation will include the facilitator’s name, professional license credentials and license number, staff signatures acknowledging completion of the training, and the date the training was completed.
The Licensee will ensure that staff understand and comply with the requirements of the regulation to promote the health, safety, and well-being of residents.
Date of Completion: 10/30/2026
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14 | Based on interviews, and record review, the licensee did not adhere to the regulation stated above and did not provide R1 with the proper services necessary to meet resident needs, which poses an immediate health, safety, or personal rights risk to residents in care. | 8
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