On 08/14/2025 LPA Mosley conducted an unannounced subsequent complaint visit. Starting at 10:40 a.m. LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns, starting at 12:30 p.m. LPA conducted three (3) in-person interviews, one (1) resident and two (2) staff including the Licensee Representative /Administrator, conducted a file review and obtained copies of pertinent documents relevant to the investigation. On 08/26/2025 at 3:04 p.m. conducted a telephonic interview with a Power of Attorney of Resident #1 (POA R1). On 08/27/2025 at 3:37 p.m. attempted to conduct a telephonic interview with Resident #1 (R1). On 08/27/2025 at 4:04 p.m. attempted to conduct a telephonic interview with a Power of Attorney of Resident #2 (POA R2). On 09/03/2025 at 10:00 a.m. LPA conducted a collateral visit to a Skilled Nursing Facility (SNF) and interviewed R1 at 11:06 a.m.

On 09/03/2025, the LPA conducted a subsequent visit at the facility. Starting at 1:25 p.m. LPA and staff conducted a brief physical plant tour to ensure there are no immediate health and safety concerns starting at 1:34 p.m. LPA conducted one (1) in-person resident interview and attempted to obtain copies of pertinent documents relevant to the investigation. On 09/03/2025 at 4:31 p.m. attempted to conduct a telephonic interview with Individual #1 (I1). On 09/03/2025 requested police report related to the incident from Ventura County Sherrif’s Department. On 09/04/2025 Received Police report from Ventura County Sherrif’s Department. On 09/04/2025 Subpoenaed hospital records for R1. On 9/04/2025 at 8:31 p.m. and 9:16 p.m. conducted a telephonic interview with Ventura County Sheriff’s Department responding Deputy (VCSD). On 09/04/2025 at 4:36 p.m. conducted a telephonic interview with Individual #2 (I2). On 09/04/2025 at 3:41 conducted a telephonic interview with I1. On 09/09/2025 received the incident report for R1 for an incident that occurred on 07/31/2025. The facility was cited on a different visit regarding reporting requirements. On 09/24/2025 at 1:28 p.m.,09/25/2025 at 8:45 a.m. and on 09/26/2025 at 3:37 p.m. the LPA attempted to conduct a telephonic interview with the POA for R2. On 09/26/2025 at 4:08 p.m. LPA attempted to conduct a telephonic interview with Responsible Person of former resident, Resident #3 (RPR3). On 09/29/2025 at 10:08 a.m and 4:38 p.m. LPA attempted to conduct a telephonic interview with RPR3. On 09/30/2025 received hospital records for R1. On 10/01/2025 at 11:46 a.m. and 4:42 p.m. and on 10/06/2025 at 10:22 a.m. LPA attempted to conduct a telephonic interview with RPR3. On 10/06/2025, LPA reviewed hospital records for R1.

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During today’s visit, starting at 9:40 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations.

On the allegation Staff pushed resident resulting in injury, it is the concern of the reporting party (RP) that Staff #1(S1) pushed Resident #1 (R1) resulting in injury and hospitalization. To investigate the allegation, the LPA conducted interviews, file reviews, and obtain copies of pertinent documents relevant to the investigation.

Interview with R1 revealed that on 07/31/2025 around 4:00 a.m. they were asleep and only remember being pulled from the bed with blood running down their forehead. R1 did not recall falling but remembers waking up injured, and a woman who suggested calling an ambulance, which was done before R1 requested it. R1 noted that no one ever witnessed S1 pushing them, however disclosed concerns to I1 and I2 about S1. R1 was afraid to disclose S1’s behavior to family in fear of retaliation. Record review revealed that R1 was admitted to the hospital on 07/31/2025 at 4:40 a.m. with multiple trauma tier two (2). It was noted that R1 is 93 years old, past medical history of diabetes hypertension and TIAs on Plavix who presents as a tier II activation. R1 is at baseline wheelchair bound but occasionally gets up to use the bathroom, on their own. R1 had a mechanical ground level fall and fell onto forehead. R1 reports generalized pain all throughout their body. No chest pain palpitations shortness of breath, no fevers, no chills, no nausea or vomiting. R1 had no acute findings in the chest, pelvis, bony abnormality, intracranial abnormalities. R1 had a large to moderate -size frontal scalp hematoma. On 08/02/2025 it was noted that R1’s pain appeared well controlled, with no current complaints of pain, field cervical collar removed, no acute fracture or cord signal abnormality. R1 was cleared for discharge from trauma standpoint. On 08/05/2025 R1 reported to POA R1 regarding abuse from S1. On 08/06/2025 hospital social worker was made aware of abuse. R1 was discharged from the hospital on 08/08/2025 at 4:50 p.m. to a Skilled Nursing Facility.

Interviews with the facility staff, including S1 revealed that on 07/31/2025 at approx. 4:00 a.m. S1 heard R1 calling for help. Upon entering R1’s room S1 found R1 face down on the floor near their commode / portable toilet beside their bed. R1 stated they fell trying to use the toilet. S1 lifted R1 and S2 noticed a bump forming on R1 forehead and called 911.

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S1 had placed R1 in a wheelchair to make the paramedic transfer easier. Shortly after, the paramedics arrived and took R1 to the hospital where they were admitted. S1 had visited R1 in the hospital on 08/02/2025 around 1:30 p.m. where R1 was asleep. S1 visited for about twenty (20) minutes to speak with the doctor however unsuccessful and left. On 08/06/2025 around 5:00 p.m. attempted to visit R1, however, was told my nursing staff they were unpermitted and left. S1 stated they were confused as to why they were unpermitted, however respected R1’s wishes. S1 describes R1 as being generally independent however requires assistance with bowel movements or with accidents. Additionally, S1 states they have never pushed any resident including R1. S1 has never witnessed any of the facility staff push a resident including R1. S2 noted that they have never had any concerns with the way S1 treated R1. S1 and R1 got along well with each other. S2 has never witnessed S1 push R1. S2 has never heard of any resident being pushed, including R1 by any facility staff.

Interview with POA R1 revealed that on 08/05/2025 R1 disclosed abuse including being pushed by S1 at the facility. Prior to 08/05/2025 POA R1 had no knowledge or suspicion of abuse from facility staff. Interviews with I1 and I2 revealed that R1 had raised concerns regarding S1, however, they never witnessed such acts. I1 and I2 reported that they noticed concerning behavior from S1 including verbal aggression and controlling actions when they were late. I1 revealed that R1 became withdrawn and quiet, which was unlike them. R1 had disclosed to I2 that S1 would poke them aggressively and was controlling, particularly at night. I2 noticed unexplained bruises on R1’s hands, which R1 attributed to falls, though they seemed uncertain. I1 and I2 never witnessed S1 push R1.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff pushed resident resulting in injury is deemed unsubstantiated at this time.

On the allegation Staff handles resident roughly, it is the concern of the reporting party (RP) that Staff #1(S1) was very rough when handling R1’s care at the facility. To investigate the allegation, the LPA conducted interviews, file reviews, and obtain copies of pertinent documents relevant to the investigation.

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Interview with R1 revealed that they were primarily independent and required little to no assistance from the staff at the beginning of their stay, however as their condition declined S1 had to assist with toileting. R1 stated that S1 would become aggressive and rough detailing being pulled from the bed and being struck by S1 sixteen (16) times in total. R1 noted they would often apologize, believing they were hallucinating and speaking to imaginary people. R1 noted that no one ever witnessed S1 handling them roughly, however disclosed concerns to I1 and I2. R1 was afraid to disclose S1’s behavior to family in fear of retaliation.

Interviews with staff including S1 revealed that R1 was occasionally provided caregiving support by the staff but was primarily independent, however declining as they became weak leading to their hospitalization. R1 had been hallucinating and reporting visions of people. There have been no reports or observations of rough handling by staff to R1 or any other residents. No disciplinary actions have ever been taken against any staff members, including S1. S1 stated they have never handled any resident roughly, including R1.

Interviews with I1 and I2 revealed that R1 had raised concerns regarding S1, however, they never witnessed such acts. I1 and I2 reported that they noticed concerning behavior from S1 including verbal aggression and controlling actions when they were late. I1 revealed that R1 became withdrawn and quiet, which was unlike them. R1 had disclosed to I2 that S1 would poke them aggressively and was controlling, particularly at night. I2 noticed unexplained bruises on R1’s hands, which R1 attributed to falls, though they seemed uncertain. I1 and I2 never witnessed S1 handle R1 roughly. Interview with POA R1 revealed that on 08/05/2025 R1 disclosed abuse including being pushed by S1 at the facility. Prior to 08/05/2025 POA R1 had no knowledge or suspicion of abuse from facility staff.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff handles resident roughly is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.