Investigator Real conducted interviews on 05/12/2025, at approximately 10:30 a.m., with one staff member; at approximately 11:45 a.m., with a hospice nurse; at approximately 12:30 p.m., with R1’s family member; and at approximately 02:30 p.m. with the Administrator. An interview was also attempted with R1 at approximately 01:20 p.m.; however, R1 was unable to respond to questions, and no information was obtained. Additional interviews were conducted by Investigator Real on 07/23/2025, at approximately 12:30 p.m. and 01:30 p.m. with two facility residents and on 07/28/2025 at approximately 01:00 p.m. with one staff member. On 07/14/2025, medical records were requested from Simi Valley Hospital and received on 07/24/2025. On 07/15/2025, hospice records were requested from Comforting Care Services and received on 07/29/2025.

A review of R1’s Physician’s Report, dated 04/01/2024, listed R1’s primary diagnosis as Alzheimer’s disease and dementia, with a secondary diagnosis of unspecified protein-calorie malnutrition. The report described R1’s mental condition as confused and disoriented, exhibiting wandering and sundowning behaviors. It noted that R1 was unable to follow instructions when confused or agitated but could follow basic instructions when not. R1 was also reported to be unable to communicate needs, except for basic and very minimal communication. The report also described R1 as non-ambulatory, with no capacity for self-care, and in need of assistance with all activities of daily living (ADLs).

The investigation revealed that on 04/13/2025, R1 reportedly sustained an unwitnessed fall from their bed. Interviews conducted with staff revealed that, following the fall, they assessed R1 and contacted the hospice agency, the facility administrator, and R1’s family. Upon arrival, the hospice nurse assessed R1 and ordered a mobile X-ray, which confirmed that R1 had suffered a fracture to the left femur. Although the fracture was confirmed, R1’s family chose to pursue comfort care at the facility. Staff reported that a brace was applied to R1’s leg. However, due to R1’s significant agitation, frequent movement, and fragile skin condition, they believe R1’s skin may have torn as a result of movement.

Report Continued on LIC 9099C...

According to hospital records dated 05/06/2025, R1, who is on hospice care, was brought in from the facility following a fall that had occurred approximately two weeks prior. At the time of the fall, staff had noted that the skin over the fracture site was taut but not broken. However, by the time of hospital admission, there was an open wound with exposed bone. Hospital staff applied traction in an effort to close the wound but noted that healing was unlikely due to R1’s age and overall condition. During the hospital stay, R1’s family reiterated their decision not to pursue aggressive treatment, prioritizing comfort, pain management, and infection prevention instead. They again declined surgical intervention. R1 was subsequently discharged back to the facility under hospice care. Verbal and written wound care instructions were provided to R1’s family to ensure appropriate ongoing care. Additionally, R1 experienced only one fall while residing at the facility, which resulted in the reported injury. Facility staff responded promptly by notifying the hospice agency, the facility administrator, and R1’s family to ensure timely medical attention.

Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegations, therefore allegations due to staff “Neglect/Lack of Care and Supervision – resident sustained unexplained fracture, staff did not properly supervise resident, and staff did not seek timely medical attention for resident’s injury” are deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy issued.