Follow-up on corrections·April 19, 2024

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Maldonado met with and explained the purpose for the visit. During the investigation conducted for a complaint, dated: 1/30/23, it was discovered that in November 2022, Resident#1 (R1) sustained a fall at the facility that resulted in a hip fracture and required surgery. At the time of the incident, R1 was not deemed a fall risk. After surgery, R1 was transferred to a skilled nursing facility to recuperate from the surgery, and returned to the facility on 12/09/22. Per facility shift report dated 1/18/23, R1 was to have status checks during night shifts every (2) hours. Per facility incident reports dated 1/20/23 and 1/30/23, it was documented that R1 sustained (2) falls on 1/20/23 at 1:45AM and 4:30AM, and (1) fall on 1/30/23 at 11:20PM. Upon being notified of more frequent falls, R1's family decided to hire a private caregiver to provide 1:1 night supervision to R1 to keep R1 from falling out of bed. Per staff interviews conducted during the investigation of the complaint, (7) of (7) staff admitted to having knowledge of R1 becoming more agitated at night and trying to get up out of bed, which resulted in frequent falls. Staff stated this was due to R1's progression of R1's cognitive impairment. After review of R1's updated facility service plan, dated: 11/25/22, R1 had a change in condition which required R1 to have hands on assistance for repositioning in bed due to becoming bedridden. Following the incident reports of falls sustained by R1, there was no update to R1's service plan/plan of care to reflect that R1 was now a fall risk. The facility failed to put a plan in place to prevent R1 from sustaining continued falls, while in care. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC809-D page. Exit interview was conducted and a copy of this report and appeal rights were provided.