Incident investigation·September 10, 2024

09/10/2024 12:45 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nicole Braswell. Today’s visit is regarding incident reports that have been submitted by the facility regarding several falls that occurred at the facility over the past 6 weeks. The purpose of the visit was for LPA to have a discussion and provide resources. Administrator stated the facility has increased their staffing in memory care, residents who are high fall risk have motion sensors in their rooms. Next month Butte Home Health is coming in to do a training on transfers, falls, and mobility at an all staff training. In order to prevent this from occurring the facility will conduct a fall prevention training with all staff. Administrator will submit a copy of the facility’s fall prevention plan to LPA. LPA referred administrator to ​​​​​​​​​StopFalls Sacramento Coalition for additional resources in fall prevention. https://dhs.saccounty.gov/PUB/StopFallsSacramento/Pages/Stop-Falls-Sacramento-Coalition.aspx No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Nicole Braswell.