complaint·October 7, 2024

It was alleged that the facility staff are not reappraising resident (R1) after falls resulting in resident sustaining injuries due to multiple falls. R1’s service plans from year 2021 - 2022 were reviewed. The review of records shows that on 04/07/2022, R1 was re-evaluated, and the fall potential section was updated from a low potential to a moderate potential for falls. The service plan included an action plan to check on R1 during med passes, meals and activities, provide night lights, arrange items within reach, slip mats in bathtub/shower, showers are draining properly, change heights of items to accommodate resident, remove trip hazards, check carpet/floor for intact surfaces, rearrange furniture if appropriate, emergency devices working and within reach, and room clutter. On 04/29/2022, R1 was re-evaluated, and the fall potential section was updated from moderate potential to high potential for falls. There were no action plans indicated on the service plan. The re-evaluation was based on a fall that was noted in R1’s record on 04/30/2022. Between 04/30/2022 – 09/08/2022, R1 was noted to have 8 falls (05/29, 06/24, 07/03, 07/05, 07/06, 08/08, 08/11, and 08/28). On 09/09/2022, R1 was re-evaluated, and the service plan was updated to still indicate a high potential for falls. The service plan included an action plan to include removing trip hazards and room clutter. Between 09/10/2022 – 11/22/2022, R1 was noted to have 14 falls (09/23, 09/24, 09/25, 10/01, 10/05, 10/07 (R1 noted to have 2 falls this day), 10/10, 10/31, 11/03, 11/05, 11/07, 11/08, 11/21). On 11/23/2022, R1 was re-evaluated, and the service plan was updated to still indicate a high potential for falls. The service plan included an action plan to use walker, arrange items to be within reach, and remove trip hazards. PAGE 2 OF 3. . The review of records show that R1 sustained injuries after falls on 08/28/2022 and 11/05/2022. On 08/28, R1 was observed to sustain a bump on his/her left forehead with redness. 911 was called and resident was not sent out after further assessment and discussion with family. On 11/05, R1 was sent to the hospital for a fall and unresponsiveness. Resident returned to the facility with the left forehead and cheeks swollen. On 11/06, resident was seen with a contusion on the right facial area post fall. On 12/12/2022, a witness observed resident was walking in the hallway without a walker with a big bump on the left forehead area. R1 denied a fall. R1 was transferred to the hospital and returned the same day with new medication. Based on record review, the facility did not re-evaluate and update R1’s service plan after falls on 05/29, 06/24, 07/03, 07/05, 07/06, 08/08, 08/11, 09/23, 09/24, 09/25, 10/01, 10/05, 10/07, 10/10, 10/31, 11/03, 11/05, 11/07, 11/08, and 12/12. The Department has investigated the above allegations. Based on record review and observation the preponderance of evidence standard has been met, therefore, the above allegations are substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. A case management visit was conducted on 10/07/2024 due to violations observed during the investigation. See LIC809 on 10/07/2024. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights were provided. PAGE 3 OF 3. It was alleged that resident (R1) sustained multiple falls due to the lack of supervision from facility staff. Based on record review, R1 sustained multiple falls between April 2022 – December 2022. The falls were noted by staff in R1’s records to either be witnessed or unwitnessed falls. R1 sustained majority of the falls in his/her bedroom. R1’s service plans on 04/07/2022, 04/29/2022, and 09/09/2022 R1 did not require staff assistance with mobility, ambulation or escorting. R1’s service on 11/23/2022, indicated that R1 may require escorts with or without the use of assistive devices to and from meals, activities and/or common areas and the plan for staff to escort R1 with his/her walker to meals and activities due to being high fall risk. On 11/05/2022, staff recommend a 24/7 companion due to frequent falls to R1’s responsible party. There is no indication that the 24/7 companion was started. R1’s signed admission agreement states that the community is not designed to provide twenty-four-hour care. It’s stated that resident may remain in the community as long as the care needs and level of functioning are consistent with those of other residents and with the level of staffing and facilities offered in the community. The Department has investigated the above allegation. Based on record review and observation, the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.