Complaint·September 30, 2021

On September 17th, 2019, R2 was admitted to the facility as a fall risk and have private caregivers to assist in the daytime. A review of R2’s care plan dated September 19th, 2019 notes that they are a fall risk but are able to ambulate independently with a steady gait and need reminders in using a walker for safety. Since the last assessment made on September 19th, 2019, R2 suffered multiple falls in the facility during the period of September 19, 2019 to December 19th, 2019. The documented incident indicates that some of these falls, witnessed and/or unwitnessed, resulted in a minor injury. There was no updated care plan to document the frequent falls for R1 and R2, and no implemented fall plan to identify staff objectives to mitigate the falls. Based on interviews conducted and record reviews, it was determined that the facility did not take measures to address multiple falls for R1 and R2. Therefore, the allegation is found to be substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted with Joey Collado, Administrator, and the Administrator was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents. However, interviews conducted with staff revealed that they were not aware of any bruising. In addition, outside source reported that R2 have been observed with a minor injury on them from a fall. Furthermore, R2 reportedly complained of pain and have indicated that they have fallen. Interviews revealed that these fall incidents have also not been reported to their respective responsible party until the facility was confronted about them. While the above listed allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and Joey Collado, Administrator, was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.