complaint·December 9, 2021

Amended from original report dated 12-9-21: Based on interview with S1 and observation, it was determined that 32 residents reside in memory care with 12 residents identified as fall risk residents. Upon LPAs review of actual hours worked by caregivers, it was determined that three caregivers were on duty during the night shift on 10-26-21 until the morning of 10-27-21. Upon further review it was determined that S2 began shift at 10:25pm and clocked out at 7:00am, S3 began shift at 8:00pm and clocked out at 3:30am, S4 began shift at 10:15pm and clocked out at 7:00am. LPA reviewed staffing schedule on 11-17-21 and interviewed S1, which reveals 3 caregivers scheduled to work during the hours of 10:30pm to 7:00am on 10-26-21 until the morning of 10-27-21. Based on interviews, observation, and record reviews it is determined that R1 resides in memory care and fell at 5:00am on 10-27-21 and sustained injuries, and upon further review, determined that only one staff was on duty in memory care and one staff was on duty in assisted living at the time of R1’s fall and without the presence of additional staff member previously on duty. Incident report states this fall was unwitnessed. Therefore, this allegation is SUBSTANTIATED. Allegation #2: Reporting party not notified of fall: LPA reviewed incident report for R1 dated 10-28-21. Based on review of incident report, there is no indication of responsible party being notified of fall incident occurring on 10-27-21 at 5:00am. Interviews with responsible person for R1 revealed no contact was made to responsible party in writing after the fall noted above. Interview with S1 revealed that it could not be confirmed if responsible party was notified of all noted above. Based on interviews and record reviews, this allegation is SUBSTANTIATED. Allegation #3: Reappraisal not completed for change of condition: LPA reviewed appraisal forms for R1 on 11-17-21. An appraisal needs and service plan for R1 was observed by LPA to be dated 2-19-21 with no update regarding fall precautions relating to the fall of R1 which occurred on 10-27-21 at 5:00am. A reappraisal form for R1 was requested on 11-17-21 and was not located in R1s record. Based on record review and observation, this allegation is SUBSTANTIATED. Allegation #4: Documents not provided to POA upon request. LPA conducted interviews with S1, and responsible person for R1. Based on interviews conducted, it was determined that a request for records relating to information on R1s fall on 10-27-21 at 5:00am was made by responsible person on 11-1-21 and not received by responsible person for R1 until 11-19-21. Based on interviews conducted, this allegation is SUBSTANTIATED. As a result of today’s visit and the findings noted above, deficiencies are cited under Title 22, division 6. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.