Inspector’s narrative
What the inspector wrote
Records Reviews
Medical record review: R1 was admitted to hospital on December 14, 2024, after an unwitnessed fall at Regency Place. According to the facility staff, they heard the fall and found R1 on the ground with a cut on the forehead. A CT scan revealed that R1 had a fracture on the right nasal bone and nasal septum. R1’s forehead wound was cleaned and closed with Steri-Strips. R1 was discharged back to Regency Place later that evening, around 11:29 p.m.
A review of R1's Needs and Services Plan, dated November 30, 2023, revealed that R1 had been identified as a
fall risk
upon admission to the facility. However, the plan does not appear to have been updated or adjusted in response to R1’s fall history, particularly the incidents in October 2024. At that time, R1 had already experienced two unwitnessed falls, and it was recommended by R1’s hospice to implement additional safety measures, such as a bed alarm or chair alarm. Through further review, there were no evidence that the facility took steps to address this recommendation until after the fall on December 14, 2024.
In October 2024, R1’s hospice documented that R1 had suffered two unwitnessed falls. Based on this, hospice staff recommended the use of a bed alarm or chair alarm to help monitor R1’s movements and helps prevent further falls. However, the facility did not implement these measures prior to R1’s fall on December 14, 2024.
Interviews:
Interviews with facility staff revealed that they believe R1 requires one-on-one care, which the facility cannot provide. Staff acknowledged that they had concerns about R1’s fall risk but indicated that they were unable to provide the necessary supervision, either due to staffing limitations or the facility not being able to meet the required level of care. Additionally, through staff interviews confirmed that facility only began implementing preventive fall measures, as recommended by R1’s hospice, after R1’s fall on December 14, 2024.
Based on the information gathered, there is a preponderance of evidence that the facility did not provide adequate supervision or implement appropriate safety measures for R1, despite being identified as a fall risk upon admission and after previous falls. Therefore, the allegation that the facility failed to provide adequate supervision, leading to multiple falls and injuries, including a fracture, is SUBSTANTIATED.
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Allegation – staff are not providing adequate care and supervision to the residents:
Observation:
During an interview with another resident R2 on 3/19/25 at approximately 10:13am, R1 was observed wandering into a R2’s room unattended. R1 was found laying on their back in R2’s bed, staring at the ceiling. R2 stated that R1 frequently engages in this behavior. When staff was called, a non-care staff arrived and escorted R1 back to R1’s own room, stating that R1 "does this all the time." This incident occurred with no apparent staff supervision in the common areas.
Record Reviews:
R1’s care plan, dated August 1, 2024, outlines that R1 is a fall risk, suffers from dementia, and requires total assistance with various activities of daily living such as bathing, dressing, and toileting. The plan specifically notes that R1 must be supervised at all times due to wandering behaviors and is also prone to aggressive and disruptive actions. However, there are no clear interventions noted in the plan to address the wandering or ensure that R1 is adequately supervised.
Interviews:
In interviews with staff, it was revealed that the memory care unit has 15 residents and is staffed with two caregivers and one medical technician per shift. The caregivers reported that they check on residents every 15 to 30 minutes. However, these checks are not consistently documented for all residents, with the exception of R1, whose checks began to be documented after the last fall in December 14, 2024, at the request of R1’s family. Despite this, staff admitted that the checks for R1 do not seem to prevent his falls, and there is no formal system to track the frequency or effectiveness of the bed alarm placed in R1’s room after R1’s injury.
R1 has experienced several falls during since admission at Regency Place. According to staff, all of R1’s falls have been unwitnessed. The most serious of these falls occurred on December 14, 2024, when R1 fell in their room, resulting in a fractured nose. Staff reported that R1 was not sent to the hospital immediately after this fall, contrary to the facility’s policy, which states that unwitnessed falls should always result in a hospital visit. Staff members also acknowledged that R1’s declining vision and refusal to wear corrective glasses may contribute to these falls.
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Staff members consistently stated that R1 requires one-on-one care due to R1’s needs, including vision impairment, wandering behavior, and aggression. However, the facility does not provide the level of care needed to properly manage R1's condition. Several staff members expressed that R1’s care needs often divert attention away from other residents, compromising the quality of care for everyone.
Multiple staff members acknowledged that R1’s wandering and fall risks increase when R1 is not closely supervised. During the night shift, staff reported that a caregiver is expected to monitor R1, but due to staffing limitations and other resident needs, this monitoring is inconsistent.
Based on the information gathered during this investigation, there is a preponderance of evidence to support the allegation that the facility did not adequate care and supervision for R1. Therefore this allegation is SUBSTANTIATED.
A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met.
Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code. Immediate Civil Penalty is being assessed in the amount of $500.00. At this time enhanced civil penalty assessments are under review and additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49.
An exit interview was conducted with S1 and a plan of corrections and the appeal process were discussed. A copy of this report and appeal rights were provided.
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