Incident investigation·December 21, 2023

On 12/21/23, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a case management visit on recent incident reports regarding falls. LPA met with the current Administrator, Elena Cuevas, and the facility Regional Health and Wellness Director, Rochelle Factor, and explained the purpose of the visit. During this visit, LPA reviewed fall incident reports and resident files for Resident_1 (R1), R2, R3, R4, R5, R6, R7 and R8. Falls were reported between the dates of 9/29/23 and 11/24/23. LPA also interviewed Elena Cuevas and Rochelle Factor. Of the 8 resident falls reviewed, 7 were unwitnessed falls. All reporting requirements for incident reports received were met per regulations. Based on interviews, it was determined that the facility has now implemented a fall prevention protocol which include frequent checks on residents in care, especially those on fall risks. Per interview, residents who had falls are put on high alert and encourage residents to enroll the EmpowerMe Wellness program which include physical therapy, occupational therapy and speech therapy. Additionally, residents who are fall risk will have their medications evaluated by their primary care physician to determine if any of their current medications can contribute to falls. Additionally, residents carry a fall pendant. Administrator and Health and Wellness Director is planning to conduct in-service training next week to address falls and incident reporting. A discovery during a resident file review that a death report was submitted to the Department on 11/13/23. However, review of the death report indicates that the date of death of the resident was on 10/30/23. Per interview confirms the date on the death report and the reporting date are accurate. Per California Code of Regulations, Title 22, deficiencies were observed or cited during today's case management inspection. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. An exit interview was conducted with Elena Cuevas and a copy of this report and appeal rights were provided.