Follow-up·March 13, 2025

On 03/13/25 Community Care Licensing division (CCLD) Staff, conducted a case management -other visit at the above facility. CCLD Staff met with Executive Director, Dawn Smith and Memory Care Director, Larianna Logan(S1) and explained the purpose of the visit was to gather information surrounding the fall of Resident #1(R1) The Regional office received a Unusual Incident Report from the facility who reported the fall. It was reported the fall occurred on 02/09/25 in the common area of the Memory Care Unit's activity area. Interview with (S1) indicated that staff (S2) and (S3) informed (S1) that (R1) had fallen on the floor of the activity area and complained of hip pain. (S2)and (S3) indicated that they were attempting to assist (R1) due to (R1) walking around in the common area carrying /dragging a blanket, in an effort to prevent an accident from occurring. (R1) became agitated which prompted (S2 and (S3) to give (R1) space and time to calm down. (R1) subsequently tripped on the blanket and fell to the floor. (R1) was taken to St. John's Providence Hospital, where surgery was performed on the hip. (R1) is currently in rehabilitation at Berkeley West, Santa Monica. (S1) indicated she has phoned family and left messages to check on resident but has not received any return calls as of today. LPA unable to interview (S2) and (S3) due to work schedule is 10 PM - 6 AM. Record review indicated (R1) on the Morse Fall Scale (MFS) indicates score of 25 - Level 2- Implement standard fall prevention interventions. No medications taken. Elopement Risk Evaluation indicates (R1) , yes - for wandering and Yes- for wandering around looking for a spouse or family member. An exit interview was conducted and a copy of this report was provided to the Executive Director, Dawn Smith.