Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein.
CCR 87466 states, “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, “will require completion of an Unusual Occurrence Report and an investigation of the circumstances leading to the fall,” and “any resident sustaining a fall will also be placed on Alert charting status.” The policy further states that an “internal Incident Report (Form 406a) is completed every time a resident falls,” and the “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.”
Review of records and interviews of staff and outside sources showed: Resident #1 (R1) fell just outside the facility’s main entrance door on 03/22/2025. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The responding facility staff, Staff #1 (S1) and Staff #2 (S2), did not timely inform any medication tech, nurse, or manager about this fall. No internal Incident Report (Form 406a) was completed for this fall around when it occurred. Also, Licensee did not timely submit an LIC624 Unusual Incident/Injury Report to CCLD for this fall (this latter element was already addressed/cited in a separate complaint report). R1’s primary care physician (i.e., the pertinent healthcare provider) was also not timely notified of R1’s fall via a Form 213a, or by any other means. [CONTINUED ON LIC 809-C, 1 of 2]
[CONTINUED FROM LIC 809] During his own 06/02/2025 site visit, LPA requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy. As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. “Alert charting” is therefore more than a cursory observation of the resident in passing, by lay staff.]
Staff interviews showed: By 03/29/2025, Staff #4 (S4), the facility medication technician who called/arranged an ambulance for R1’s confusion and elevated blood pressure, was still unaware that R1 had fallen a week earlier. Likewise, the nurse manager then overseeing the facility’s clinical operations, Staff #5 (S5), and their deputy supervisor, Staff #7 (S7), both did not become aware that R1 had fallen a week earlier, until after R1 was already at the hospital. While there is no regulation specifically addressing internal communication, the failure of staff to internally communicate in this instance evidenced Licensee falling short of its own policy/procedural requirements regarding post-fall observation of R1. (In the final analysis, CCLD’s investigation showed that R1’s fall was not a proximate cause of R1’s confusion or elevated blood pressure. However, S4, S5, and S6 each affirmed to LPA that knowing about a prior fall provides useful context needed to inform subsequent observation checks and incidental medical care decisions, and that S1 and S2 should have reported the fall per protocol, when it occurred.)
Additionally, during an earlier 06/23/2025 site visit, a California Department of Social Services (CDSS) Investigator (a peace officer acting in an official capacity on behalf of CCLD) formally requested from facility manager S5 a copy of the surveillance camera video footage segment depicting R1’s aforementioned fall on 03/22/2025. As of the date of this 06/23/2025 request, the pertinent footage was still intact and viewable, as witnessed by the Investigator. The Investigator made multiple follow-up phone calls to S5 for a copy of this footage for CCLD’s case file, but it was not provided to the Department. The Investigator subsequently spoke to the new facility administrator on 10/03/2025, who reported that as of that date, the pertinent footage no longer existed. [CONTINUED ON LIC 809-C, 2 of 2]
[CONTINUED FROM LIC 809-C, 1 of 2]
Two (2) deficiencies were cited according to California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee.
An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
