Complaint·May 14, 2026

The investigation revealed the following: Regarding the allegation, Staff did not properly address resident's multiple falls at facility, it is alleged that staff did not prevent Resident #1 (R1) from sustaining multiple falls while in care within a two year period. LPA inspected the facility, conducted health and safety checks on residents in care, and did not observe any health and safety issues during the visits. R1 moved into the memory care facility on October 4, 2021, and based on the Physician’s Report dated October 1, 2021, R1 was ambulatory, able to communicate needs, and had a diagnosis of Alzheimer’s Disease Dementia with delusions and behavior issues. A Physician’s Reports dated March 20, 2024 indicated R1 was non-ambulatory, able to communicate needs, and had the same diagnosis. LPA reviewed R1’s Physician Fax Communications sent by the facility and hospital discharge records which state that: on June 1, 2023, R1 sustained an unwitnessed fall and taken to the hospital for evaluation by family; on October 27, 2023, R1 was assessed by Home Health, was able to ambulate with normal gait pattern and with noted instability; on December 4, 2023 R1 sustained a witnessed fall resulting in R1 hitting their head and was transferred to the hospital for evaluation; on February 2, 2024, R1 was transferred to the hospital due to a fall; on February 24, 2024, R1 sustained an unwitnessed fall resulting in rug burn, an abrasion on her right elbow and first aid was applied; on February 25, 2024, R1 had an unwitnessed fall, ambulated and expressed pain on right elbow; on March 3, 2024, R1 sustained an unwitnessed fall in a common room, was able to ambulate and had no signs of pain or injuries; on April 7, 2024, R1 sustained an unwitnessed fall in their bathroom and staff observed bruising from a previous fall. Based on records reviewed, R1 nine sustained falls between June 1, 2023 and April 7, 2024 and voluntarily moved out on May 16, 2024. The facility held multiple care plan meetings between October 4, 2021 and February 1, 2024, however, R1 was not assessed to be a high risk for falls and additional measures to address R1’s fall risk were not included. Four out of four staff interviewed stated they are unaware of the fall prevention measures put in place for R1 and the facility was unable to provide any fall prevention plan documentation during the course of the investigation. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had concerns about the care R1 was receiving at the facility but did not provide any supportive evidence. Continue to LIC9099-C..... Even though R1 had no visible injuries during some of the falls, it was imperative that facility document and implement a fall prevention plan specific to R1’s Dementia diagnosis. Therefore, based on the Department’s interviews that were conducted and the records reviewed, the preponderance of evidence standard has been met, and the following allegation: Staff did not properly address resident's multiple falls at facility is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC9099D. An exit interview was conducted with Administrator Christine Greenway, a copy of this report, LIC809-D, LIC811, and appeal rights were provided at the end of the visit.