complaint·August 17, 2023

Allegation: Resident sustained injury, fracture to spine, as a result of a fall: Substantiated The department conducted a records review, staff and residents’ interviews to investigate this allegation. From record review, it has been observed that R1 fell in the bathroom while S1 was assisting them on 02/14/23. Facility sent out R1 to the hospital to get medical care after the fall incident where R1 was diagnosed with a fractured neck which required surgery to fuse the C1 and C2 vertebrae. During hospital stay, R1 health declined and was placed on hospice care in March 2023. From resident’s interviews, it has been concluded that R1 sustained a fall on 02/14/23 due to staff’s (S1) lack of supervision and care. Facility management received complaints regarding S1’s work ethic, including S1s disappearance during their working shifts. During a department interview with S1 regarding the fall R1 sustained on 02/14/23, S1 did not provide clear answers on what happened at the time of R1’s fall. During the staff’s interviews, the department interviewed S4 who worked with S1 on 02/14/23. S4 stated that there was a lot of miscommunications that occurred during the shift. S4 stated that they were on their lunch break and heard the radio go off at least eight (8) different times during their 30-minute lunch break to assist R1 back to her room. S4 was called to assist after the fall had occurred with R1 and stated that S4 believed the fall happened due to an improper transfer because of the way R1 was laying on the floor. During staff interviews, S1 stated that they were frustrated and overwhelmed the night R1 fell (02/14/23). S1 stated that they had been working a double shift. S1 acknowledged that R1 was left in a hallway unattended for at least 40 minutes before S1 arrived to assist. S1 admitted that S1 had never worked with R1 before 02/14/23 and was unfamiliar with R1’s needs. S1 assisted R1 back to their room and R1 in their wheelchair. S1 answered the radio and retrieved some items she had dropped. During this time, S1 observed R1 turn their wheelchair and move towards the restroom for approximately 30 seconds before R1 fell. Based on review of R1’s facility assessment and needs and service plan which was conducted on 02/01/23, R1 required 1-person total assistance with toileting and transferring. Additionally, R1 was noted as a fall risk and required supervision to reduce the risk of falls. Based on this information, the allegation’ Resident sustained injury, fracture to spine, as a result of a fall’ is found to be Substantiated. **continued on 9099C..... Allegation- Facility is not meeting resident's needs. -SUBSTANTIATED. The department conducted a records review, staff and residents’ interviews to investigate this allegation. From record review, it has been observed that on 02/14/23, R1 fell in the bathroom while S1 was assisting R1 to the bathroom. Facility sent out R1 to the hospital to get medical care after this fall incident at which time R1 was diagnosed with a fractured neck which required surgery to fuse the C1 and C2 vertebrae together. During hospital stay, R1’s health declined and R1 was placed on hospice care in March 2023. From residents’ interviews, it has been concluded that R1’s fall on 02/14/23 was due to staff’s (S1) lack of supervision and care. R1 moved to the facility on 02/01/23 and based on R1’s facility assessment and needs and service plan, R1 required 1-person total assistance with toileting and transferring. Additionally, R1 was noted as a fall risk and required supervision to reduce the risk of falls. Record review and interviews indicated that facility did not provide proper care and supervision which resulted R1’s sustaining a fall on 02/14/23 causing serious bodily injury to R1. The allegation’ Facility is not meeting resident’s needs’ is found to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6. 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. Allegation- Facility did not ensure that activities are available for residents- UNFOUNDED. The department conducted a record review, facility observations and staff and resident’s interviews to investigate this allegation. Interviews conducted with staff indicated that there is always a facility staff person in the memory care unit to do activities with residents. LPA observed multiple facility staff to be present during exercise class on 08/08/23 in the morning time during facility’s tour and observed that 20-25 residents were present in that activity session in memory care unit. LPA observed a large monthly activities calendar posted as well as a daily hour schedule of activities in the communal of the memory care unit. Records review and interviews found that the licensee employs a full-time activities coordinator for the assisted living and for memory care unit. Specific to residents in memory care, activities are available and utilized when or if residents can participate. Residents’ interviews indicated that the facility was providing meaningful activities daily to residents and did not express any concerns. Based on information obtained, LPA finds the above allegation to be UNFOUNDED. Allegation-Facility did not ensure that resident's room maintained cleanliness. - UNFOUNDED LPA investigated the allegation, "Facility did not ensure that resident's room maintained cleanliness ". On 08/08/23, LPA conducted a facility tour which included residents’ rooms, medication room, and common living spaces in the memory care unit and assisted living areas of the facility. LPA observed that the facility was clean, safe and sanitary and odor free. LPA interviewed staff, and all staff who stated the housekeepers keep the facility clean and are cleaning daily. LPA interviewed residents in care in which they stated the facility was always clean. Due to the information gathered, LPA finds the allegation to be UNFOUNDED. Allegation- Facility not allowing resident to eat in the dining room. - UNFOUNDED The department conducted staff and residents' interviews, reviewed records and facility observations to investigate the allegation. During residents interviews, it has been found out that residents can request meal tray service to their rooms if they do not want to eat in dining room. Residents stated that there have been no issues with tray delivery service to their rooms and they can choose where they want to eat. Staff interviews indicated that they were not aware of any issues with residents’ meal services. During the department visit on 08/08/23, LPA observed residents were enjoying their breakfast in their rooms and in the dining area. Based on the information, this allegation is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.