Incident investigation·May 28, 2025

05/28/2025 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding two incident reports that were submitted to licensing regarding incidents that occurred on 04/15/2025 and 05/22/2025. Both of these incidents resulted in residents sustaining fractures related to falls that occurred in the facility. On 04/15/2025 Resident 1 (R1) pushed their PHB was complaining of left hip pain and wanted to go to the hospital to be checked out and get x rays. EMS was called and resident was transported to local hospital for evaluation. R1 was admitted to hospital with a diagnosis of hip pain and a fractured sacrum. During the investigation it was learned that on 3/04/2025 R1 was walking their dog and fell. R1 was sent out to hospital for evaluation and sent back with pain medication. On 04/07/2025 R1 had bruising due to an unwitnessed fall and was sent out again with no findings. On 04/15/2025 R1 had unmanaged pain and was sent out to the hospital, and was diagnosed with fractured sacrum. R1 was still experiencing pain so the facility sent R1 back to the hospital and they were discharged with stronger pain meds, home health, and physical therapy referral. Continued on LIC809-C On 05/22/2025 Resident 2 (R2) pushed their pendant and when staff arrived they found R2 on the floor in their bathroom. R2 stated they were attempting to transfer themselves and fell. R2 was assessed for injury and was found to have two skin tears on their left hand. R2 complained left hip pain and left knee pain. EMS was called and R2 was transported to hospital for evaluation and subsequently admitted with diagnosis of left hip fracture. During the investigation it was learned that R2 normally does transfer themselves during the day. In the morning R2 is assisted by staff to get out of bed, get dressed, and brush their teeth due to being in a wheelchair. That morning R2 attempted to transfer themselves and did not lock one side of their wheelchair and subsequently fell. R2 is currently hospitalized and scheduled for surgery. It is anticipated that R2 will be transferred to skilled nursing after surgery for rehabilitation. In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Administrator will submit a copy of the facility’s fall prevention plan to LPA. LPA referred administrator to ​​​​​​​​​StopFalls Sacramento Coalition for additional resources in fall prevention. https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.