complaint·January 18, 2023

Regarding the resident sustained injuries while in care, R1 fell over nine times between 07/24/2022 and 10/06/2022. On 10/03/2022, facility staff reported that R1 fell and sustained a laceration below R1’s eyebrow and a black eye. Facility staff placed steri-strips on R1’s laceration, but R1 was not sent to hospital and R1’s family was not notified. On 10/06/2022, R1 fell three times before R1 was sent to the hospital. According to a review of medical records, R1 sustained a closed C2 fracture and a right vertebral artery dissection. Facility staff reported that R1 required a higher level of care and should have been moved sooner. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated at this time. Regarding the resident suffered multiple falls while in care, facility staff were aware that R1 was falling, was weak and hallucinating. According to a review of incident reports and progress notes, R1 had over nine documented falls between 07/24/2022 to 10/06/2022 and not all falls were documented. Facility staff said that they could not provide one on one supervision and R1 kept forgetting to ask for assistance. Facility administrator said that the facility administrator was not notified on 10/03/2022 when R1 fell and sustained a laceration below R1’s eyebrow and the facility administrator was not notified when R1 fell on 10/06/2022 until after R1 had fallen three times. A fall prevention plan was never implemented. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated at this time. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties. At the time of the complaint inspection on 1/18/2023, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. An exit interview was conducted, and a copy of this report dated 1/18/2023 along with Administrator. Appeal Rights (LIC 9058) was provided to Administrator Lucinda Fonseca whose signature below confirms receipt of these rights.