other·March 4, 2022

of resident, staff, other residents and Administrators on January 18, 2020; January 21, 2020; January 24, 2020; January 30, 2020; and February 04, 2020. Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed. On January 15, 2019, it was documented that R1 was agitated and attempted to get out of bed and was assisted by staff. Somehow an unwitnessed fall occurred and R1 got out of bed alone, fell backward, and hit R1’s head on the wall. R1 sustained “several bumps.” On December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported during the investigation by IB Investigator Santana that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. Further, staff left R1 unattended even though R1 was at risk of attempting to get out of bed. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. The facility accepted and retained the resident, knowing R1 was a “high fall risk.” Due to the lack of care and supervision by staff, R1 sustained multiple bruises and a head injury. Also, during the incidents of the falls, facility staff failed to seek medical attention and notify R1’s responsible party in a timely manner. This is an immediate health and safety risk to residents in care. Therefore, there is evidence to corroborate the investigation conducted by IB, and the allegation “Use of Improper Restraints Resulting in Injury to Resident”, is Substantiated. Allegation # 2: Failure to provide adequate Observation of Resident's Condition . On January 13, 2020, LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed. Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed. It was also reported that on December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported, that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. Through all the information obtained, interviews and documentation, the facility updated R1’s needs and service/appraisal plan on February 05, 2020, a year later, to address the issues and problems the facility was experiencing with R1. And because the facility accepted and retained R1, knowing R1 was a “high fall risk” and diagnosed with a mental health condition. This is an immediate health and safety risk to resident in care. There is sufficient evidence, the facility, This is an immediate health and safety risk to resident in care. There is sufficient evidence, the facility, “ Failed to provide adequate observation of resident’s condition”, therefore the allegation is deemed SUBSTANTIATED. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights given. A copy of the report was issued. Based on the information obtained, LPA determined that the facility provided musical activities monthly for the residents at the facility. LPA was able to observe videos of residents singing and dancing. And interviews revealed that staff assisted resident #1 (R1) to participate in the activities, but due to R1’s physical and mental disabilities, there were times R1 was not able to participate, based on R1’s tolerance. LPA was unable to interview any residents, due to the residents no longer living at the facility, at the time R1 was admitted. There is no evidence to support the allegation the facility failed to provide sufficient activities; therefore, the finding is UNSUBSTANTIATED at this time. Allegation # 4: Failure to provide meals of adequate quality: Concerns were expressed, the facility failed to provide meals of adequate quality. On January 13, 2020, former LPA Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed. Based on the information obtained, it was revealed, resident #1 (R1)’s appetite was sporadic, and had difficulty eating, due to missing teeth. Staff was instructed to cut R1’s food into small pieces or puree. R1’s appetite fluctuated and would go days without eating and would spit out food. It was also reported that there were never any complaints or concerns expressed to the Administrator or staff in regard to the types of meals that were being provided to R1 or other residents. Based on interviews, there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation # 5: Failure to Provide Sufficient Staff: Concerns were expressed, the facility failed to provide sufficient staff. On January 13, 2020, former LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed. Information, and documentation obtained, including interviews, revealed there are (3) regular staff, including (2) Administrators that work in mornings. Administrator also reported to LPA that, they use other caregivers from other owned facilities (Cottages of Lake Balboa 2 and Cottage of Lake Balboa 3), which are adjacent to each other to cover staffing as needed. LPA observed the facility and requested the staff schedule and resident list. In the evening, there (2) PM staff, depending on the census. During the graveyard, it was reported that there could be at least (2) overnight staff that cover. Although, during the incidents with resident #1 (R1), who had (2) un-witnessed falls, it was revealed that there were (2) staff working the graveyard shift, which according to the census at the time R1 was residing, there was sufficient staff. Also, during facility visits during the investigation, LPA witnessed sufficient staff. Therefore, at this time, based on the information, observation, and interviews, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted and a copy of the report was issued.