complaint·July 10, 2024

...Continued from LIC 9099 The first unwitnessed fall was discovered by S2; documents support that care staff (caregivers) helped R1 up and provided first aid to her finger. The second unwitnessed fall, S1 delayed reported that around 1120 hours, she observed R1 on the floor in front of a chair she was previously sitting on at around 1100 hours. Staff assisted R1 to her feet and, as per interviews, guided her back to the dining area before later presenting her to her family for a visit. Care staff did not notify the nurse on duty for additional assessment for both unwitnessed falls. On the allegation: Staff did not report incident to CCL. Based on interviews and records review the facility did not report to the department that R1 had 2 unwitnessed falls on June 16, 2022. In an interview with S1 said that for both falls reported by S2, facility was not able to find the incident reports or the COC report to provide to CCLD. On the allegation: Staff did not communicate with the responsible party of incident. Based on interviews and records review the facility did not report to R1’s family the residents change of condition or falls that occurred. In an interview with the investigator S1 confirmed that no one updated R1’s family about the investigation. Based on the investigation, above allegations are deemed Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.