complaint·March 13, 2025

The allegation of “Staff are not properly supervising residents who may be a fall risk” alleges that the facility did not provide appropriate supervision and safety measures for resident #1 (R1) which resulted in R1 being hospitalized after experiencing a fall at the facility. LPA observed the resident file for R1. LPA observed the file to contain an LIC 625 Appraisal Needs and Services Plan, a Care Center Discharge Summary, and a Home Health Certification and Plan of Care that indicated R1 had a history of and was at risk for falls. During the initial 11/12/2024 visit LPA Balisi interviewed the Administrator who stated that R1 had bedrails previously equipped on their bed. The Administrator stated that due to them not having an order for bed rails and due to recent visits from licensing they were afraid of getting a citation, so the facility removed the bedrails. The Administrator stated that the bedrails were originally installed at the request of the family, but they were removed pending an order from R1’s home health agency. During today’s visit LPA Byrne interviewed the Administrator. The Administrator stated they were unaware that R1 was a fall risk before they arrived to the facility. The Administrator stated that upon identifying R1 as a fall risk they would place a protective mat on the floor alongside R1’s bed at night to mitigate the fall risk but no additional safety measures were put in place during the day. The Administrator estimated that the approximate time from the home health nurse leaving to when facility staff found R1 was 5-10 minutes. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff are not properly supervising residents who may be a fall risk” Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22 regulations and/or the Health and Safety Code the following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.