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32 | 9099C-1. Allegation: Facility staff failed to properly supervise residents resulting in resident being attacked and hospitalized for injuries. The allegation states on Sunday, March 30, 2025, a resident walked into the resident's (R1's) room while (R1) was sleeping and attacked (R1) who sustained a fractured vertebra and a dislocated joint in the hand.
Staff interviews conducted and documentation reviewed confirmed that on March 30, 2025, resident (R2) entered (R1's) room, at approximately 9:30 am, and physically attacked (R1) while (R1) was sleeping. Staff who was present and observed (R2) enter (R1's) room stated they followed (R2) into the room one to two minutes later and observed (R2) to be standing over and hitting (R1) who was resting in bed. Staff called for a second staff to assist with separating the residents from each other. Both residents were sent out for further medical evaluation following this incident.
Medical records note that (R1) was sent out to the emergency room at one hospital and diagnosed with “Scapholunate dissociation, unspecified laterality (primary encounter diagnosis), Closed compression fracture of L3 lumbar vertebrae, initial encounter, Rib pain. (R1's) family member confirmed that (R1) was diagnosed with a fractured hand/wrist and fractured lower back. Documentation reviewed confirmed that (R2) was sent to a different hospital and diagnosed with a "behavioral problem". Interviews and documentation concluded that (R2) has a known history of aggression towards residents and staff and had previously attacked (R1) on at least two separate occasions.
The Department was told by (3) facility staff during interviews that (R2) should have been placed in a higher level of care facility, such as a skilled nursing facility. Further, interviews and documentation revealed that although (R2's) initial placement was appropriate, (R2) had several changes in condition, including increased aggression, wandering and sundowning and should have been removed from the facility.
After the third unprovoked altercation between (R1) and (R2) the facility began to implement 1:1 care/supervision with (R2), which is not a service the facility provides, and began hiring a staff to provide the this care/supervision through an outside agency. The facility failed to implement reasonable and timely interventions to mitigate known risks, leading to neglect.
Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. |
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32 | 9099A-C-1.. LPA reviewed one report completed by (S1) and submitted to the Department following the incident on March 25, 2025 which states (R1) stepped in when (R3) was yelling at (S1) and "while the exchange of words escalated quickly and before the Med-Tech could step in, the punch was thrown". The report continues "Med-Tech intervention separated the two and I believe only one punch was thrown by (R3). (R1) did not throw any punches". (S1) commented in an interview to LPA that (R3) "was sweet but then could get really agitated" and explained "(R3) had a 1:1 the whole last month they were here, in June, due to their behaviors".
A second staff who was interviewed stated in July 2025 that she recalls (R1) and resident (R3) but doesn't recall an altercation between these two residents. This staff commented (R3) moved out recently and confirmed (R3) had a 1:1 prior to moving out earlier this month. This staff was asked if she feels the facility has sufficient supervision for residents and responded "it depends on the resident's mood as much as the supervision". This staff added, "we get a lot of staff from a temporary staffing agency" and indicated she feels these staff "are doing a good job".
A third staff stated in July 2025 that she was not at the facility when (R3) had the fight with resident, (R1) but she "heard about the altercation" between these residents. This staff confirmed she provided prior resident, (R3) with 1:1 care/supervision but was "not aware of the reason why (R3) had 1:1", commenting, "I followed (R3) everywhere". The Administrator stated that (R3) was given 1:1 care/supervision following an incident on June 25, 2025, when (R3) hit another resident with a fork. LPA was shown documentation of the 1:1 following the incident. It appears the incident occurred so quickly on March 25, 2025 that (S1), who was present during the entire incident, was unable to prevent (R3) from punching (R1).
Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Allegation: Due to lack of supervision, multiple residents are assaulting other residents. The allegation states a couple of months ago, a female resident pulled a chunk of hair out of (R1')s head. For the past 3 weeks there have been multiple residents assaulting other residents.
*cont on 9099C-2.. |
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32 | 9099A-C-2.. A review of charting notes for (R1) documents that (R2) went into (R1's) room on October 25, 2024 (11:00 pm) where there was a verbal altercation, resulting in (R2) puling (R1's) hair out. The notes say (R1) was okay and just "shocked' and (R3) was helped back into their room.
LPA conducted a review of incidents occurring in the month of March 2025. Resident charting notes and incident reports documents the following incidents:
The Administrator confirmed that on March 25, 2025 (7:00 pm), (R3) became agitated in the TV/Lobby room and got into a physical altercation with (R1), and punched them in the face, hitting them in the eye and then kicked staff who tried to separate the altercation. Following the incident, the shift lead contacted 9-1-1 to transport (R3) to the hospital for further medical evaluation. (R3) returned from the hospital on March 26, 2025 (1:08 pm), groggy from the medication given at the hospital.
The facility submitted a report for suspected abuse on March 26, 2025, following an incident occurring on March 26, 2025 (7:45 am). The incident involved( (R2) entering (R1's) room and scratching their arm. The report notes that a Med-Tech was called to (R1's) room after (R2) went in (R1's) room and scratched them. The report notes the event was unwitnessed. (R1) indicated the event was an unprovoked event. (R2) was sent out for further medical attention due to showing agitation and aggression. When a non-emergency ambulance provider arrived to evaluate (R1), (R1) requested to be sent to the hospital.
Charting notes document that on March 28, 2025 (3:00 pm), (R3) got into an altercation with resident (R4) in the dining room. (R3) stated to staff that another resident (R4) hit her first. The Administrator referenced a report that (R3) was observed to have red marks in the face but didn't need to be sent out.
Charting notes cite other instances where residents (R2 and R3) were aggressive with staff members. The facility conducted staff training related to abuse/aggressive behaviors on April 10, 2025, June 10, 2025, June 17, 2025 and on July 25, 2025.
Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Exit interview. Copy of report provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/30/2025
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements - General (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 evidenced by: | 1
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7 | Licensee/Administrator began 1:1 supervision with (R2) following the incident on 3/30/2025 but (R2) moved out on 3/31/25. The Administrator created a policy (on 4/8/2025) addresing when 1:1 staff should be implemented for a resident with behaviors or for other reasons.
Training to be conducted in August for all staff, including newer staff, on August 10, 2025. |
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14 | Based on interviews conducted and documenation reviewed, the Licensee did not ensure that adequate supervision was provided to (R2) and (R1), prior to March 30, 2025 (9:30 am) when (R2) entered (R1's) room and attacked (R1) while (R1) was resting, which poses an immediate health and safety risk to residents in care. (R2's) care plan, (dated 7/1/2024), notes that resident requires "maximum assist" with staff monitoring behavioral expressions and resident has had "some expressions that Admin is monitoring closely". | 8
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14 | A CIVIL PENALTY IS BEING ISSUED IN THE AMOUNT OF $1,000.00 ALSO. |
Type B
08/12/2025
Section Cited
CCR
87463(a)(1)(C) | 1
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7 | 87463 Reappraisals (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to: (C) Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This requirement is not met as evidenced by: | 1
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7 | Licensee/Administrator agree to continue to review each resident's care plan after a behavioral expression, or fall, and update the "Behavioral Expresssion Appraisal and Plan" or "Post Fall Assesment Plan" as needed. A Post-Fall Assessment is completed when the LIC624 is completed. |
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14 | Based on documentation reviewed, the Licensee did not ensure that resident (R2's) care plan was updated following resident showing a change in condition with behaviors/behavioral expressions documented back to October 2024 through March 2025, which posed a potential health and safety risk to residents in care. | 8
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14 | (R3) moved out of the community on/around March 31, 2025. Currently there are no residents with aggressive behaviors.
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