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Inspection visit

Complaint

GRACES HOMELicense 3060054701 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Although R1 did sustain an unwitnessed fall, it remains unclear if the fall was caused due to a lack of supervision on behalf of facility staff. Based on the investigation, the allegation that Facility did not provide adequate supervision resulting in resident jumping out a window was found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report, and confidential names list was left at the facility. CONTINUED...When Interviewed by the Department and asked why they did not have R1 transported to the hospital, R1’s responsible party stated they believed R1 to be improving and didn’t think the situation was serious despite R1’s continued inability to walk. R1’s primary care physician was not contacted nor notified of the fall at the time of incident. During a visit to the facility on 11/09/2022, R1’s responsible party requested R1 be taken to the hospital for evaluation on their hip. R1 was taken to the hospital approximately a month after the initial fall where they were diagnosed with a displaced left hip fracture. The Administrator reported they expected that the family would handle R1’s medical needs. R1’s responsible party told hospital staff they were unable to take R1 to the hospital sooner due to being busy. Hospital records reviewed note that R1’s responsible party reported R1 was not brought in by their caregiver as the caregiver had two other people to take care of. R1’s responsible party reported to hospital staff R1 has memory difficulties and is often confused. R1’s family declined surgical intervention due to R1’s age. R1 eloped from the hospital prior to being discharged with the assistance of their responsible party and returned to the facility against medical advice. R1’s physician report dated 7/12/2022 lists R1 as ambulatory prior to the fall. Following the fall, R1 was unable to walk and relied on a wheelchair for transportation. An interview with R1’s responsible party confirms that R1 is no longer able to ambulate following the fall. Based on the investigation, the allegation that Facility staff did not seek medical attention for resident in a timely manner was found to be SUBSTANTIATED. The following is being cited per California Code of Regulations, Title 22 Division 6 Chapter 8. A civil penalty is pending determination, per H&S Code Section 1569.49(f). An exit interview was conducted with Administrator and a copy of this report, confidential names list, civil penalty, and appeal rights was provided at the time of exit.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)(D)Type B

    87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…A written report…Any incident which threatens the welfare, safety or CONTINUED... health of any resident…This requirement is not met as evidence by: Licensee failed to submit a written report to the Licensing agency regarding R1’s unwitnessed fall in October of 2022 or hospitalization on 8/26/22. This poses a potential risk to residents in care.

  • 87405(d)Type A

    Required administrator qualifications listed in this subsection

    87405(d) Administrator- Qualification and Duties. The administrator shall have the qualifications specified…Knowledge of the requirements for providing care and supervision … and ability to conform to the applicable laws, rules and regulations. This CONTINUED... CONTINUE...requirement was not met as evidence by: Administrator failed to ensure the facility was properly staffed; failed to submit necessary written reports to licensing and failed to seek appropriate medical attention for R1. This poses an immediate risk to residents in care.

  • 87411(a)Type A

    Facility personnel sufficiency and competence

    87411(a) Personnel Requirements- General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement was not met as evidence by: The facility failed CONTINUED... CONTINUE...to seek immediate medical attention for R1 in part due to the caregiver needing to care for two other residents. The facility lacked sufficient staffing to be able to meet the resident’s need for immediate medical attention. This poses an immediate risk to residents in care.

  • 87463(c)Type B

    Document behavioral expression and related causes

    87463(c) Reappraisals. The licensee shall arrange a meeting … when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by: Following R1’s fall the facility failed to CONTINUED... CONTINUE...complete a reappraisal despite R1 being unable to walk. R1 was able to walk with assistance prior to fall. This poses a potential risk to residents in care.

  • 87465(g)Type A

    Call 9-1-1 for imminent health threats

    87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This regulation was not met as evidence by: Resident was found on ground CONTINUED... CONTINUED...following an unwitnessed fall sometime in October of 2022. Despite reporting hip pain and being unable to walk, no medical attention was sought. R1 was transferred to the hospital approximately a month later and diagnosed with a hip fracture.

FAQ · About this visit

Common questions about this visit

What happened during the April 24, 2023 inspection of GRACES HOME?

This was a complaint inspection of GRACES HOME on April 24, 2023. 1 citation were issued: 1 Type A (serious).

Were any citations issued to GRACES HOME on April 24, 2023?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Departmen..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.