complaint·December 6, 2023

Per the South Placer Fire District Prehospital (SPFD) Care Report, it was noted that staff reported R1 may have fallen into the water about an hour prior to SPFD being dispatched to Granite Bay CountryHouse LLC. After reviewing observation notes, it was determined R1 had approximately six witnessed falls and 12 unwitnessed falls, between 4/10/2022 to 8/30/2023. With the number of falls R1 had, staff were asked what they were doing to prevent R1 from falling. Staff indicated they were just “keeping an eye” on R1. R1’s care plans dated 2/25/2022 and 10/5/2023 noted that R1 requires two safety checks during the nighttime. However, the care plans did not indicate any special checks throughout the day or indicate that R1 was considered a fall risk. Per the Hospice “IDT” notes dated 11/17/2022, R1 was noted to become more dependent on care and can no longer walk due to wheelchair bound restriction. Additionally, it was noted on 11/4/2022, that R1 was a fall risk due to their fractured left foot. Staff reported that there are no specific procedures if a resident is considered a fall risk. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility.