The Cottages of Lake Balboa 1

Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...the licensee shall ensure that such changes are documented...This requirement was not met as evidenced by: during the investigation, the facility accepted and retained R1, when knowing R1 was a “high fall risk.” Because of the improper use of bed rails, the impact of the fall caused severe injuries to R1. This is a potential health and safety risk to residents in care.

Postural Supports: (a) Based on the individual's preadmission appraisal..for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports maybe... used to achieve proper body position and balance...but not limited to, preventing a resident from falling out of bed..This requirement was not met, evidenced by, based on incident reports, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). and R1 sustained serious injuries. This is a potential health and safety risk to resident in care.