Follow-up on corrections·March 13, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for complaint # 59-AS-20231226105149 and met with Toni Jones, Administrator. LPA explained the reason for the inspection. During the course of the investigation, LPA reviewed several unusual incident/injury reports (SIR) for resident (R1). One SIR reports (R1) having an unwitnesed fall on 10/5/23 in the dining room at approximately 8:45 am. The report states that care staff reported that resident was upset and “having an expression” and trying to get out of the wheelchair. Afterwards staff observed resident had a bump on her forehead, she was sent to the hospital for further evaluation. Resident returned to the community the same day with the recommendation to follow up with her primary care physician in 4-7 days. Interviews with the Administrator and family member confirmed that the care staff (S1) who was with resident when she began to enter a behavior, left the resident unattended, to get another staff to assist, when resident fell out of her wheelchair and sustained bruising on her head and face. Resident’s family member stated staff (S1) walked away from (R1) on 10/5/23 which caused her to fall on her face. The family member provided (2) photos showing a head injury on resident's right side, above the eyebrows, and clarified that when staff walked away, resident stood up and then fell flat on her face. A subsequent incident report was submitted on 10/9/23 for an incident occurring on 10/8/23 (2:30 pm). (R1) was observed to not be at baseline and to be screaming so was given a PRN medication for pain. Resident was sent to the emergency room later in the day, complaining of pain, and was diagnosed with pneumonia and a concussion from the previous fall from 10/5/23. Resident was prescribed levofloxacin and placed on alert charting until returning to baseline. *cont on 809C-1 809C-1.. § 1569.626 Training requirements for direct care staff states in part: (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. LPA reviewed training records for staff (S1), who began working as a care giver on 6/28/23. The records document that (18) hours of training was completed from 6/28/23 through 7/4/23 and (1) hour was specific to Dementia care.