complaint·February 23, 2022

On 9/13/21, Resident #1 (R1) fell in R1’s private apartment at the facility and sustained three broken toes. R1 was interviewed and stated R1 is independent and able to ambulate without assistance from staff. R1 tripped on a mat in the sewing room and was unable to get up. R1 pressed pendant and staff responded. Call log shows pendant was pressed at 12:30pm and acknowledged in 12 minutes. R1 was not a fall risk with no history of falls. On 9/14/21, Resident #2 (R2) fell in the community restroom at the facility and sustained a fracture vertebra. R2 said, R2 fell after using the restroom when going to the sink to wash hands. R2 pressed pendant for help. Call log shows pendant was pressed and acknowledged in 12 minutes. R2 was not a fall risk and was able to ambulate at the time of the fall. On 9/13/21, Resident #3 (R3) fell in R3’s private apartment at the facility and sustained a fracture to the humeral head. R3 was interviewed and could not recall details of what happened. Call log shows R3 pressed pendant at 8:16 and staff responded in 11 minutes. R3 previously fell in June 2021 and had not had any falls since. R3 was able to be left unsupervised in her room. R3 medical records indicate R3 was able to ambulate with a walker. This department has investigated the complaint. Based on records reviewed and interviews conducted with residents and staff, the allegations that multiple residents fell and sustained serious injuries due to lack of supervision and staff do not attend to resident’s pendant calls in a timely manner, is UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred . Per California Code of Regulations, Title 22, no citations were issued. An exit interview was conducted, and a copy of this report was given to Deborah Taylor.