complaint·April 8, 2025

Staff did not provide adequate supervision resulting in resident sustaining a fracture while in care. Staff did not prevent resident from suffering multiple falls while in care. On July 16, 2024, R1 sustained a fall in the facility. Hospital medical records stated that on July 16, 2024, R1 sustained a broken left collarbone. Hospital Doctor confirmed that R1’s CT scan of spine showed a “comminuted left clavicular head fracture.” Doctor stated that the injury was an acute injury and was consistent with someone sustaining a fall. R1 reported they were in their room walking with their walker alone when R1 sustained a fall. R1 remembers bleeding “a lot” from their head. R1 did not know where facility staff were at the time of R1’s fall. File review documents do not document a specific fall plan for R1. A review of R1’s file indicated the facility conducted (2) two Reassessments on R1. Initial assessment at time of move in dated March 1, 2023, and June 20, 2024 due to a change in condition. R1 Needs and Service plans indicated R1 requires a personalized interventions per fall management protocol however the facility was unable to provide documentation with the personalized interventions the facility put in place to assist for R1. Facility staff interviewed reported that R1 sustained approximately 20 plus falls while at the facility. The facility did not have a clear plan in place to keep R1 from continuing to sustain these falls. Previous Administrator Lydia Gravelyn and another staff stated they believed R1 required a higher level of care than the facility could provide. R1 would constantly refuse care and assistance from facility staff, yet the facility allowed R1 to continue constantly falling while at the facility. The medical records obtained support that R1 sustained multiple falls resulting in head injuries and a clavicle fracture. Each fall was a result of R1 attempting to do things on their own rather than requesting assistance from facility staff. Facility file review records document R1 sustained 15 falls between 3/9/2023 and 7/16/2024. Facility failed to develop a personalized intervention plan as indicated in R1's needs and service plan resulting in R1 sustaining many falls at the facility including the fall R1 sustained on July 16, 2024, which caused R1 a serious injury. The above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $500 is assessed. The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49. Exit interview conducted. Appeal rights provided. Report left with facility Administrator.