Inspector’s narrative
What the inspector wrote
transported to the hospital for weakness, a CT scan showed a blood clot in R1’s brain, physician note states R1 fell a week prior and the blood clot was a result of the fall. It was alleged there was no call button accessible for R1 and staff did not provide a plan in place to prevent R1’s multiple falls.
LPA reviewed R1’s facility record, a Physician’s Report LIC602A dated November 15, 2024 states R1 is diagnosed with multiple diagnoses including Parkinson’s, Wernicke’s, and orthostatic hypotension; R1 has unsteady gate at times, is confused/disoriented, has wandering behavior, able to follow instructions at times and communicates needs most of the time. R1’s needs and services plan/care plan dated December 14, 2024 is marked “yes” next to falls and notes dizziness when standing; however, it does not discuss any plan or mitigation measures for R1’s falls or unsteady gait. Staff interviews, including with the licensee, revealed the facility does not have a fall mitigation plan, but staff were making efforts to monitor R1 by using a motion sensor alarm next to R1’s bed and more frequent checks. Interviews revealed R1 refused to use a walker or cane due to not knowing how to use it. The facility capacity does not require call buttons, and the licensee stated they did not provide one to R1 due to their mental status.
Regarding the incident around Easter 2025, review of R1’s hospital and facility records did not reveal a fall incident occurring on or around April 20, 2025. Staff interviews revealed they are not aware of an occasion around Easter 2025 when R1 fell in their room and the floor alarm was not working.
LPA review of hospital records revealed R1 visited the hospital due to a fall on the following dates: March 19, 2025 resulting in a skin tear to the right elbow; on July 6, 2025 resulting in a laceration of the nose closed with stitches, laceration to the forehead closed with stitches and a skin tear to the left elbow; on August 15, 2025 resulting in a scalp laceration closed with staples. Community Care Licensing (CCL) received incident reports from the facility regarding the falls on March 19, 2025 and July 6, 2025. An incident report for the August 15, 2025 fall was submitted to the department on October 14, 2025.
(Continued on LIC9099-C)
Review of facility documentation revealed the following narrative notes regarding R1: On August 24, 2025, Staff found R1 on knees in the grass. No visible injuries.; August 30, 2025 R1 was dizzy today and had several unwitnessed falls. Caregivers thought R1 fell on their knees because they only saw scrapes on R1’s hands and knees and nothing on R1’s head.; September 1, 2025 – R1 fell on the grass outside; September 3, 2025- R1 was feeling sleepy and unsteady much of the day. Staff kept wheelchair close to R1. R1 was walking outside had an unwitnessed fall, scraped their knees, and staff cleaned their wounds; September 4, 2025- R1 fell a couple of times and it looked like R1 just scraped their knees. CCL did not receive incident reports for these incidents and there is no record or documentation of medical services provided to R1 at the time of these incidents.
On September 13, 2025 R1 went to the hospital due to an increase in weakness. A CT scan of R1 conducted on September 13, 2025 noted, VENTRICLES/SULCI: Acute on subacute holoconvexity left-sided subdural hematoma measuring up to 1.2 cm. There is extension into the left tentorium measuring 3 mm. 7 mm subacute holoconvexity right-sided subdural hematoma. Mass effect from these bilateral subdural hematomas on the adjacent cerebral parenchyma. CEREBRUM: No evidence of parenchymal hemorrhage in or large territorial infarction. Mild 3 mm rightward midline shift. The previous CT scan of R1 conducted on August 15, 2025 noted VENTRICLES/SULCI: No evidence of ventricular, subdural or subarachnoid hemorrhage.
Overall, R1 experienced at least eight documented falls, of which five were unwitnessed, while at the facility between March 2025 and September 2025. Despite the continued falls, the facility did not update R1’s appraisal/care plan or implement additional mitigation techniques to address fall safety. Additionally, interviews revealed R1 frequently wandered around the yard, sometimes without staff supervision.
Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. A civil penalty of $500 is assessed for injury to a resident.
(Continued on LIC9099-C)
On allegation, staff did not properly meet resident’s dietary needs, it was alleged R1 has lost a lot of weight. R1 had a personal supply of Ensure provided by R1’s family, but staff do not provide it to R1 and are giving R1’s Ensure to other residents to consume. R1 requires soft/chopped foods and on one occasion R1 was served a hot dog not cut up resulting in R1 choking, being transported to the ER, and staff said they forgot to chop up the hot dog. Two weeks later R1 was served hot dogs again, left whole and not chopped. It was alleged in March 2025, R1 was dehydrated and went to the ER.
Review of R1’s facility record revealed a form titled Facility Vital Signs and Weights with documentation of R1’s weight on 7/10/2024 at 175.4, on 9/20/2024 at 172, and on 12/23/2024 at 170; no additional weights were recorded although R1 lived at the facility until September 2025. A physician order dated 4/25/2023 for R1 states “Ensure, or equivalent, one bottle po with meal TID”. Interviews revealed staff were providing one Ensure to R1 at breakfast, but not three times a day per physician’s order. LPA interviews with staff revealed that R1 did have a personal supply of Ensure drinks that were kept in the kitchen pantry, they were not always given to R1, and some of the other residents were served R1’s Ensure drinks. When this was discovered, the facility procedure changed to store R1’s personal supply of Ensures in the locking medication cart to be distributed by the medication technician. Technical assistance to ensure residents personal belongings are safeguarded was provided to the Licensee.
A physician order dated 12/19/2024 states “Mechanical Soft diet due to choking incidents”. Hospital records for R1 reveal a visit on May 7, 2025 for choking due to hot dogs, staff performed Heimlich maneuver and dislodged the hot dog. Staff interviews revealed there have been times they forgot to provide R1 a mechanical soft diet.
Regarding the dehydration in March 2025, hospital and facility record review reveal no diagnosis of dehydration for R1.
Based on all interviews conducted and documents obtained, at this time the above allegation was found to be
substantiated
, there is a preponderance of the evidence to prove that the alleged violation occurred.
(Continued on LIC9099-C)
On allegation, staff unable to communicate residents needs due to language barrier, it was alleged there is a language barrier between R1 and staff when R1 asks for assistance.
Interviews revealed six of six residents in care and R1 communicate in English. Staff interviews revealed there are two to three staff whose native language is Spanish and these staff cannot effectively communicate with the residents verbally. Staff state an effort is made to schedule these staff to work with staff who can communicate with the residents in care, but there have been times when the only staff working at the facility have not been able to effectively communicate with the residents. Interviews revealed there have been times the residents have been upset not being able to make their needs known to the staff. During staff interviews, LPA was unable to effectively communicate with several employees due to the same language barrier reported by residents.
Based on all interviews conducted and observation at this time the above allegation was found to be
substantiated
, there is a preponderance of the evidence to prove that the alleged violation occurred.
Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to Licensee. An immediate civil penalty in the amount of $500 is being assessed on the attached LIC421IM, report signed, report and appeal rights provided to the Licensee.
Review of R1’s Centrally Stored Medication and Destruction Record (CSMDR), Medication Administration Record (MAR), PRN Report, and th
e Medication Transfer Sheet/Release of Responsibility maintained by the facility reveal R1 was receiving their medication as prescribed by their physician.
Between January 2025 and September 2025, 36 PRN doses of Seroquel (quetiapine) 25mg were given, not exceeding the physician’s order. There is no evidence the facility provided R1 with more of their mediations than prescribed by their physician.
Based on all interviews conducted and documents obtained, at this time the above allegation was found to be
unsubstantiated
.
Exit interview conducted, report signed, and report provided to Licensee.
