Murrieta Gardens.

(Continuation from LIC9099) Administrator reported that the hospital staff reviewing the x-ray elevated their concerns when it was later discovered that prior chest x-rays showed the rib fractures. A records review was conducted of the facility’s Unusual Incident Reports. A report dated 6/29/2025 documented an unwitnessed fall in which R1 was found seated on the floor, at the base of the couch. She was transported to the hospital for evaluation, where it was confirmed that no injuries were sustained. A report dated 7/20/2025 documented that R1 had exhibited signs of pneumonia and was transported to the hospital by their responsible. This incident is the direct subject of the current investigation. Other than these two reports, no additional incidents involving R1 have been reported. Interview with R1 report that R1 slipped off the couch earlier that year but does not recall sustaining any injuries. An interview with R1 and their responsible person report that R1 was in a major car accident in the 1990’s causing R1 to sustain multiple rib fractures. R1 responsible person reports that the prior fracture was still shown in the x-ray, but the area of the fractures is healed. Interview with R1 confirmed that there is no residing pain from the prior rib fractures and does not recall the last time when R1 experienced pain in that area. Attempts to interview Witness #1 (W1) were unsuccessful. Additional information received document “Per provider, radiologist re-reviewed imaging from previous visit and the rib fractures were present at the time, just didn’t get notated. Plan for DC back to Murrieta Gardens”. Based on interviews and records review, the allegation of “staff did not prevent a resident from sustaining a fracture while in care” is deemed unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted where this report was discussed and provided to Administrator.

(Continuation from LIC9099) Interview with S2 reported that S2 was standing near the entryway of the main room when S2 overheard a loud slapping noise. S2 reportedly rushed towards the noise and observed R2 with their hand raised and began hitting R1 with an open hand. S2 reported observing S1 separating the resident and S2 assisted with redirecting R1 away from R2. After the residents were separated, staff reported that S2 contacted emergency personnel as R1’s left side of the forehead had light bleeding. Staff report that R1 had prior stitching due to an unrelated incident. As a result of the physical altercation, a stitch on R1’s forehead was removed. Staff interviews reported that S2 contacted emergency personnel. Upon emergency personnel’s arrival, R1 was transported to the hospital due to the stitch being removed from R1’s head. Interviews with staff and Witness #1 (W1) reported that R2 was not observed to have sustained any injuries. Staff interviews reported that R2 does not have a history being physically or verbally aggressive towards residents and does not require constant care and supervision. LPA attempted to interview R1 and R2 but due to cognitive abilities, the interview attempts were unsuccessful. A review of R2’s care plan details that R2 requires checks at more frequent interval and may exhibit physically or verbally aggressive behaviors. A review of R1’s care plan detailed that R1 requires checks a regular intervals and has a history of aggressive behaviors in prior facilities. Records review conducted for R1 and R2 does not report either residents requiring constant care and supervision. Interview with Administrator explained that regular checks are conducted every two hours and frequent checks are conducted every hour. LPA was informed that the facility does not maintain surveillance cameras in that location of the building. Due to insufficient evidence, the allegation of staff did not prevent one resident from hitting another resident is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Administrator Kylee Carter.

On 10/6/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required visit. LPA met with Administrator, Kylee Carter, and explained to Kylee the purpose of the visit. Administrator Kylee granted LPA entry to the memory care facility. During the visit, LPA conducted a tour of the facility and observed the following: The facility is a two-story structure which consist of (61) sixty-one units. The facility is licensed for (126) one hundred and twenty-six non-ambulatory residents to which (20) twenty may be bedridden on the first level only. The Licensee was observed to be operating with their scope. LPA observed kitchen to be clean and free of rubbish. Food is stored in a safe and healthful manner by ensuring all food items were properly dated and free of mold. Utensils and dishware are sufficient for the approved capacity. LPA observed food supply met the requirement for a (2) two-day supply of perishable food and (7) seven-day supply of non-perishable food. Sharps are secured in the locked kitchen and inaccessible to the residents. During the visit, LPA observed food staff preparing food. All persons engaging in food preparation and service were observed to maintain personal hygiene and proper sanitation practices to protect the food from contamination. Indoor/outdoor passageways were observed to be free of obstruction. Fire extinguisher is charged and up to date. Resident bedrooms were observed to be equipped with the required bedding, furniture, seating, and functional lighting. Resident bathrooms were observed to have working toilet, sinks, and were equipped with a grab bar in the shower and toilet areas.LPA observed laundry room to be clean and inaccessible to residents as it housed cleaning supplies. Washing machine and dryer were observed to be in good repair. LPA observed sufficient amount of extra towels and linen located in the laundry room. (Continue to LIC809C...) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continuation from LIC809C...) The facility exits were equipped with permitted egress devices to ensure resident safety. All outdoor pathways were free of obstructions. No bodies of water were observed. Licensee promotes socialization by organizing (3) three or more planned activities to encourage physical activities, interactive games between residents, and host socializing events. The facility maintains sufficient space to host these interactive planned activities. A fire alarm service test report was conducted on 04/23/2025 by Murrieta Fire and Rescue. The report indicated the fire alarm system to be in good repair. Per Administrator, there are no firearms and/or ammunition on the premises. LPA conducted records review of (7) seven residents. Resident records included but not limited to preplacement appraisals, assessments, medical and dental, needs and services plans, physician reports, personal rights, signed telecommunication device notifications, property and valuables, and admission agreements. LPA conducted (3) three staff records. Staff records included but not limited to valid CPR/First-aid Certification, health screenings, valid TB test, criminal record clearance, personnel record. job application, and training's pertaining to job functions. An exit interview was conducted and a copy of this report will be provided to Administrator, Kylee Carter.