complaint·March 20, 2025

The investigation revealed the following: It was alleged, staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries. Resident 1 (R1) moved to the facility on September 2, 2023. R1 was diagnosed with a major neurocognitive disorder, osteoporosis, kidney disease, hypertension, and depression. R1’s physician’s report dated August 15, 2023, has R1 listed as ambulatory. R1 was able to ambulate and transfer independently at the time of move in. In December of 2023 R1 had a fall that resulted in a hip fracture. Witnesses interviewed reported that R1 began to decline after this fall and became a fall risk. The facility assessment for R1 dated August 23, 2023, states R1 does not have a history of falls and is not a fall risk. The facility assessment for R1 dated May 2, 2024, shows R1 requires a walker and wheelchair and is a fall risk. Hospital records from April 25, 2024, show R1 is a fall risk. R1 was admitted to Hospice on February 7, 2024. A review of R1’s care notes show, R1 suffered falls on April 3, 5, 25, 29, and 30 of 2024. Two of the falls resulted in R1 being transferred to local hospitals. On April 25, 2024, Staff found R1 on the floor with a bump on the head along with bruising on the right side of their face. R1 was transported to St. Jude Medical Center. R1 was diagnosed with a closed head injury and a closed fracture of the nasal bone. R1 was treated and released back to the facility the same day. On April 29, 2024, R1 fell and was found on the floor by staff. R1 was transported to Kaiser Permanente Hospital. R1 was diagnosed with a head injury and a left knee contusion. On April 29, 2024, R1 was admitted to Home Health due to the head injury and the left knee contusion. Resident returned to the facility the same day. Staff interviewed reported that R1 had a wheelchair and a walker but would still attempt to walk without the use of assistive devices. The Health and Wellness Director reported that the facility implemented a fall intervention plan which included increased checks on R1 to once an hour, a lower bed and a fall mat placed next to the bed. R1’s Responsible Party verified this information. Five out of eight staff members interviewed reported that R1 had increased checks after the May 2, 2024, assessment was completed. Staff reported that all interventions they placed on R1 to prevent falls did not work. There is no documented evidence of a specific fall prevention plan. R1’s Primary Care Physician (PCP) reported the facility never consulted with them regarding R1’s falls to determine the best level of care for R1. R1’s Hospice Doctor reported the facility never consulted with them regarding R1’s care. A review of R1’s service plans from August 23, 2023, and May 2, 2024, shows an increase in service regarding mobility/ambulation. The Health and Wellness Director reported that they offered R1’s responsible party a one-on-one care companion at the end of March 2024 or early April 2024, but they declined the offer. The Health and Wellness Director reported they suggested a different facility which could provide a higher level of care, but the responsible party declined. R1’s responsible party only verified the recommendation for a one-on-one care companion. The service plan for R1 was updated on May 2, 2024, after R1 had 5 falls. There is no record of R1 falling after April 30, 2024. On May 1, 2024, Hospice, Facility staff and R1’s Responsible Party had a meeting to discuss R1’s change in condition and need for one-on-one care. The Responsible Party declined one-on-one care due to financial reasons. On May 2 the Hospice provider and R1’s Responsible Party had a meeting and Hospice recommended R1 be placed in a higher level of care, but the Responsible Party declined, so the facility placed R1 in another room which allowed for closer supervision. Facility staff acknowledged that R1 continued to fall despite their fall intervention plan and the facility retained R1 knowing they did not have adequate and supervision to meet R1’s needs. R1 remained at the facility until they passed away on June 3, 2024, cause of death was respiratory arrest and senile degeneration of brain not elsewhere classified. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation that staff did not provide adequate supervision, resulting in a resident sustaining multiple injuries. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.