Complaint·May 7, 2025

***Report continued from 9099.... Allegation- Resident sustained multiple unwitnessed falls due to staff neglect Based on documentation, between 03/12/2024 and 01/14/2025, R1 sustained nine unwitnessed falls in R1’s bedroom and one witnessed fall in the common area. Based on interviews, neither R1’s responsible party, or facility staff recommended a change in R1’s care plan or provided R1 with some type of ambulatory aid to possibly prevent R1 from falling. R1’s responsible party provided R1 a portable bed rail; however, R1 would remove the rail from the bed. Additionally, interviews revealed that neither R1’s responsible party nor facility staff recommended the use of an ambulatory aid because R1 would have “refused” to use it. Summerfield of Roseville has four neighborhoods on the premises: Garden, Tuscan, Apple, and Seaside. Seaside is a neighborhood for residents who need a higher level of care. Facility staff explained the residents living in Seaside can be considered fall-risks, may be wheelchair bound or receiving hospice services and require two-staff assistance. It was not recommended by facility staff that R1 move into this neighborhood for the higher level of care and supervision until 01/15/2025. Based on the findings, staff were neglectful in preventing R1 from sustaining falls while in care, therefore, the preponderance of evidence standard has been met, this allegation of Neglect/Lack of Care and Supervision is SUBSTANTIATED . Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. Appeal rights provided. Report left with facility staff. Resident sustained a fracture due to staff neglect Based on records reviewed, on 01/04/2025, around 1100 hours, R1 sustained an unwitnessed fall in R1’s bedroom. S1 located R1 on the floor next to R1’s bed. R1 complained of having back pain. S2 called emergency services and R1 was transported to the hospital by ambulance. Per medical records, R1 arrived at the hospital on 01/04/2025, at 1115 hours. X-Ray images revealed that R1 had sustained an acute fracture of the transverse process of vertebra L1. Based on staff interviews and employee timesheets, R1 was last checked on by S1 on 01/04/2025, around 1000 hours, before S1 clocked out for S1’s lunch break at 1001 hours. Upon S1 returning from S1’s lunch at 1033 hours, S1 conducted another check on S1’s assigned residents, to prepare them for their lunch at 1130 hours. Considering the approximate one hour and fifteen-minute timeframe between R1 being checked on and R1 arriving at the hospital, I determined staff’s supervision of R1 was appropriate, and staff were not neglectful in their care; therefore, this allegation of Neglect/Lack of Care and Supervision is UNSUBSTANTIATED . A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Report left with facility.