complaint·August 4, 2021

Allegation 1: Neglect/Lack of Care and Supervision: The lack of care and supervision by facility staff resulted in resident sustaining multiple falls with injuries. Findings: Substantiated Resident 1’s (R1) Needs and Services plan as of 5/25/2021, indicated R1 is a high fall risk due to weakness, mentation, and medications. R1 requires frequent checks and anticipation of needs. Event Reports regarding R1 for the months of 3/1/2021 to 6/11/2021 were obtained by Lassen House Senior Living. There were 13 Event Reports obtained and 12 of the 13 Event Reports were about R1 having a fall. A witness reported R1 has fallen multiple times. R1 has multiple skin tears and bruises on themselves that the witness could not tell which tears were new or old. A review of SECH medical records indicated R1 was transported to the hospital eight times due to unwitnessed falls within three months. On 3/26/2021, SECH medical records indicated R1 had a small hairline fracture on their left seventh rib. SECH medical records stated R1 had multiple skin tears and bruising. Staff reported the facility is understaffed. Staff stated if the facility was fully staffed, the majority of the falls would have not happened. Staff stated residents are checked every hour, but if a resident is considered a fall risk, they are checked every 30 to 40 minutes. Staff estimated R1 had about 15 falls within the last six months. Staff stated residents are checked every two hours. Based on the investigator’s review of R1’s Care History regarding the two hours checks, it is unclear if R1 was checked on every two hours. For an example, there are three entries for the same date and time. Continued on LIC9099-C ALLEGATION 2: Resident 's personal rights to staff that are sufficient in numbers, qualifications, and competency to meet their needs were denied. Staff reported the facility is understaffed. Staff stated if the facility was fully staffed, the majority of the falls would have not happened. Staff stated residents are checked every hour, but if a resident is considered a fall risk, they are checked every 30 to 40 minutes. Staff estimated R1 had about 15 falls within the last six months. Staff stated residents are checked every two hours. Based on the investigator’s review of R1’s Care History regarding the two hours checks, it is unclear if R1 was checked on every two hours. For an example, there are three entries for the same date and time. Based on the interviews and evidence obtained by Department of Social Services Community Care Licensing Investigations Branch, the preponderance of evidence standard has been met, therefore, the above allegations are found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided, and an exit interview conducted.