complaint·May 9, 2023

The complaint alleges that R1 sustained multiple injuries while in care. Record review revealed that R1 is ambulatory and has wandering behavior. Needs and service appraisal indicates R1 is at risk for falls related to unsteady gait. Interviews revealed that R1 had been residing at the facility for some time at the time of the complaint allegation, so the staff were familiar with R1’s care needs and behaviors at that time. Facility staff were aware of R1’s behavior and falls and had met with R1’s family members and physician approximately 7 months prior to discuss changing R1’s medication and additional care needs. At that time, licensee representative had issued a verbal eviction notice to R1’s Responsible Party (RP.) However, written notice was not issued to the RP. Following the meeting, facility staff provided additional supervision to R1 in order to mitigate unwanted behaviors and decrease R1’s fall risk, including additional visits by the facility designee. Interviews revealed that the additional supervision provided was successful, however toward the end of December 2020, staffing plans changed due to COVID and the facility designee was no longer conducting additional visits. Interview revealed that R1 fell around 4:30AM on 02/16/2021. Staff informed facility designee via telephone and facility designee visited the facility at 2:00PM and observed bruising on R1’s arm. This incident was not reported to CCL, nor was documentation of notification to R1’s physician provided. Interview also revealed that R1’s responsible party was not informed of this fall. Additionally, the facility did not conduct a needs and service appraisal identifying R1’s changing needs nor was additional supervision provided to R1 although previous additional supervision was successful in limiting R1’s behaviors and fall incidences. Then, on 02/20/2021 at 04:00AM, R1 fell a second time, resulting in bruising on R1’s forehead. Facility designee was informed via telephone and arrived at the facility around 01:00 or 02:00PM to observe the resident’s bruising. At that time, the facility staff called 9-1-1 and R1 was taken to the hospital for further evaluation. Based on interview and record review, there is sufficient evidence to support the allegation, therefore, the allegation that “resident sustained multiple injuries while in care” is deemed SUBSTANTIATED at this time. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $1000. Facility designee was informed that failure to correct the deficiency may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.