Follow-up·August 9, 2023

On 08/09/2023 at 9:40 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management visit concerning the 08/07/2023 unwitnessed fall that resulted in the death of R1 that was reported to the Department in a Death Report dated 08/08/2023. Upon entry, LPA stated the purpose of the visit to Care Coordinator (CC) Jio Alonzo. During the inspection, the LPA observed R1's room, interviewed staff CC Alonzo and Administrator Jay Grutas (who was present during the incident). LPA also reviewed R1 and facility files. It was staff change time when the incident occurred, so a full complement of direct care staff members were present, at least 8. At the time of R1's fall at 7:09 PM, staff were following facility protocol for residents at a high-risk of falling: half bed rail, elevated legs, fall mat, and both a bed and motion alarm in the room. Staff member S1 was in R1's room within a minute of the alarms being triggered, providing first aid. Immediately thereafter, staff member S2 called 911. Then, they notified R1's Attorney-In-Fact and physician. By 7:15 PM, the fire department and paramedics were in R1's room caring for him. By 7:40 PM, the first responders had departed for John Muir Hospital with R1. Based upon the data collected from the interviews, file reviews, and facility observations, the staff and administration of the facility operated in accordance with Title 22 regulations and in the best interest of resident R1 before, during, and after R1's unwitnessed fall that caused a break in his cervical vertebrae and ultimately his death on 08/08/2023. No citations were issued during this inspection. Exit interview conducted with CC Jio Alonzo. A copy of this report provided via email.