complaint·August 9, 2022

A resident (Resident 1) sustained multiple falls at the facility . During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, the Resident’s Assessment document and photos. It was reported and verified by Incident Reports that a resident did sustain multiple falls at the facility. In one fall, it was reported that the resident suffered a head injury and a black eye (photo reviewed). The facility completed the Activities of Daily Living Basic Care Services for the resident. The checklist for item #3 states “How much assistance does the resident require with mobility and transfers?” A check mark is listed for “Walks with supervision or ambulation devise.” In addition, the resident’s Physician Report states that the resident has “Motor Impairment/Paralysis from post hip surgery, need assistance.” On the Appraisal/Needs and Services Plan it is stated “Functioning Skills – Difficulty in developing and/or using independent functioning skills, cannot function on own.” Three different documents supported that the resident was a fall risk and needed assistance and supervision when walking. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Staff did not seek medical attention for a resident (Resident 1) in a timely manner . During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and to include Physician’s Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, the Resident’s Assessment document and photos. It was reported and verified by Incident Reports that a resident did sustain multiple falls at the facility. It was reported in a fall, during the nighttime shift, the resident fell and suffered a skin tear from her wrist to near elbow (photos reviewed). It was reported that the staff person did not contact Emergency Services (911); however, rather bandaged the skin tear herself. Several hours went by before the morning shift arrived, observed the seriousness of the skin tear wound and sent the resident out to the hospital. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D continued A resident's (Resident 1) belongings were misplaced . During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained to include Physician’s Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, Personal Property and Valuables document and the Resident’s Assessment document. Most staff and others reported that the residents at the facility have dementia and that they do have a tendency to walk away with other resident’s items. The Property and Valuables List document was reviewed, and it did not have the resident’s items listed, but rather a “slash” through the document and the Power of Attorney’s (POA) signature. A list of the resident’s items were not listed. It was reported that when the resident moved out, her belongings were misplaced and were not available for her to take them with her, which included some garments and shoes. The facility staff reported that they have obtained some of the resident's items and are available to be picked up at the front office. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.