Follow-up on corrections·February 2, 2023

Licensing Program Analyst (LPA) Bains arrived at the facility unannounced on 02/02/2023 to conduct a case management visit at the facility. LPA met with facility Administrator Adam Hill and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened by facility staff upon entry. LPA Bains came to facility to conduct a case management visit due an incident that occurred at the facility for R1 for 06/06/2022. On 06/08/2022, the facility submitted an incident report to the Department indicating R1 sustained a fall incident at the facility on 06/06/2022 which resulted in R1s death at hospital on the same day. A review of additional incident reports submitted by the facility to the Department for R1 indicated R1 sustained falls on 05/0722, 05/26/22, 05/28/22 and 06/03/22. The Department investigated the incident and concluded that the fall R1 sustained on 06/06/2022 contributed to R1’s death. R1’s certificate of Death identifies “Cause of Death” as Acute Subdural Hematoma with Shift, Mechanical Fall, Acute Respiratory Failure, and Acute Cardiac Arrest; and states R1 suffered an unwitnessed, ground level fall. Medical reports indicated R1 underwent a Computerized Tomography (CT) Scan upon admittance to the hospital which showed R1 suffered a Holohemispheric Subdural Hemorrhage, a fatal injury, because of an unwitnessed fall that occurred at the facility on 6/6/2022. ** continued on LIC809C.......** *** Continued from LIC809........ Based on interviews with facility staff, staff were aware R1 was a fall risk as R1 fell twice (5/26/2022, 6/6/2022) in the hallway and three times (5/7/2022, 5/28/2022, 6/3/2022) During investigation, facility staff members (S1, S2, S3, S4) stated they were not instructed by management to provide any additional care to R1other than to “keep an eye on her” in case she was to fall. In addition, facility management staff stated that they did not issue special instructions to staff on additional care for R1 relating to her falling and that they did not believe R1 falling in the future could be avoided. Furthermore, management staff stated that their efforts were on R1s family obtaining Hospice Care for R1s to assist in R1s care. In addition to R1’s falls, care notes indicated the facility observed R1 with a decline in heath. R1s overall health was never re-evaluated by R1s physician; therefore, R1 never received an updated Needs and Services plan to prevent future falls. Although the facility notified R1’s physician and responsible party of R1’s decline and falls, the facility did not reassess R1 due a change in condition after facility observed R1’s decline and R1 sustaining multiple falls. The facility did not put a plan in place for R1 to mitigate the risk of falls. Based on investigation conducted, facility staff were aware R1 was a fall risk and did not put measures in place to provide adequate care and supervision to R1 resulted in R1 sustaining multiple falls that contributed to R1’s death. The citation issued today is under review and a future civil penalty may apply based on Health and Safety code §1569.49(e) H&S. In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal Rights provided. A copy of the report issued.