Incident investigation·November 1, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a continuation of a case management – incident visit from 08/04/2023. LPA met with Executive Director, Paula Spanek. On 08/04/2023, LPA Dolores arrived to the facility to conduct as case management – incident visit based on an incident report and death report received for resident (R1). On 08/04/2023, the Assistant Executive Director was interviewed. Documents were obtained throughout the investigation to include resident (R1)’s physician’s report, functional capabilities assessment, individualized care plan, face sheet, progress notes, medical records, fax notifications to physician, police report, verification of death, and death certificate. Based on interview and record review, it was found that on 07/19/2023 resident (R1) was moved from Assisted Living to Memory Care due to a change of condition. Resident was noted to be a fall risk and sustained frequent falls in the community. On the morning of 07/28/2023, R1 sustained a first fall in Memory Care. R1’s family was notified via telephone and physician was notified via fax. The facility did not conduct a re-assessment for R1 after the first fall in memory care. On the night of 07/28/2023, R1 sustained a second fall. Resident did not complain of any pain or discomfort. Staff continued to monitor R1's condition post-fall. Based on record review, there was no indication R1’s family or physician was notified of the second fall. On the night of 07/29/2023, R1 sustained a third fall and was pronounced deceased by the paramedics. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director, Paula Spanek and a copy of the report and appeal rights were provided.