complaint·August 14, 2024

The investigation revealed the following: Regarding the allegation “Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care” it is being alleged that R1 has a history of falls and head traumas; and the licensee has not created fall prevention plan for R1 and has not assisted R1 in attaining Durable Medical Equipment (DME) for example walkers, wheelchairs, devices that assist residents in their daily activities. Record review of R1’s medical history indicate that R1 fell on: 7/7/21, 10/19/21, 10/31/22, 12/3/22, 9/9/23, 6/8/23, 6/13/24, and 8/8/24. R1's medical history shows a history of head tramas due to falls. R1 was receiving physical therapy for the month of 09/2023 and medical documentation indicates “assistive device is needed” for example, “FWW” (front-wheeled walker) and that R1 is a fall risk. LPA did not observe a fall prevention plan for R1. R1’s Appraisal/Needs and Services Plan does not include fall prevention. Interviews conducted reveal the following: R1 does not have an assistive walking device and R1 does not have a fall prevention plan. Observations reveal the following: LPA did not observe durable medical equipment in R1’s bedroom but LPA did observe handrails in R1’s bathroom. Regarding the allegation “Staff did not ensure supervision was provided resulting in resident sustaining an unexplained injury while in care,” the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Administrator along with their appeal rights.