Incident investigation·July 27, 2023

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with facility staff Hanna, and explained the purpose of the visit. LPA was later met by Administrator Karly Sturgeon. LPA followed up on 2 incident reports, 1 death report, and provided information on an exception request. An incident occurred with Resident 1 (R1) where R1 had an unwitnessed fall and was found by staff on the floor with blood. R1 was transported to the hospital and returned with no new orders. R1 was placed on fall monitoring and the facility implemented the chair monitor. LPA observed the chair monitor locate do on the wheel chair. There is a clip that gets attached to R1's shift collar and if R1 gets up, the alarm will sound. An incident occurred with Resident 2 (R2) where R2 had an unwitnessed fall and was found on the floor by staff. R2 was observed to have skin tears on elbow and forehead. R2 was evaluated by the hospice nurse. R2 was put on alert charting and has a chair alarm to notify staff. LPA received a death report for Resident 3 (R3). According to the administrator, R3 was on hospice and died of natural causes. Per California Code of Regulations (CCR) - Title 22 - no deficiencies were observed. An exit interview was held, and a copy of the report was provided.