Two days later on October 3, 2024, Resident had a second unwitnessed fall at 12:27pm. Per facility med tech, R1 was evaluated to have no injuries noted. R1’s Power of Attorney (POA) was contacted and POA requested R1 not be sent out to hospital. The facility did not seek immediate medical attention. Resident was assisted into wheelchair and was monitored every two to three hours.

Two weeks later, on October 17, 2024, at 10:15am, R1 was in the hallway near room #307 and stepped on a weigh scale; used to measure residents. Per Medical Technician (MT), R1 was observed to have fallen backwards onto the floor. MT denied observing R1 hit their head. R1 was assessed by MT who observed no injuries noted. Following the third fall that month, the facility implemented increased monitoring of R1. R1 was frequently checked and monitored every two to three hours and staff were instructed to clear trip hazards as reported on Unusual Incident Report on October 18, 2024.

On November 3, 2024, at 9:50am R1 was observed on the ground in the Memory Care patio. R1 had a laceration to the left eyebrow and lower lip and complained of neck pain. 911 was called and R1 was transported to UCI Medical Center for further evaluation. Upon return to the facility on November 4, 2024, a Care Plan meeting was held with R1’s POA and facility Administrator and Wellness Director. During the meeting the facility recommended for R1 to receive hospice services. Quality Hospice was initiated on November 5, 2024. Quality Hospice noted R1 had an unsteady gait and documented fall precautions, such as unobstructed pathways and that frequent checks should be implemented.

On December 16, 2024, Resident had another unwitnessed fall at 12:57pm and was found by facility staff. R1 sustained a hematoma on left eyebrow area and left nostril per MT assessment. Quality Hospice and POA were notified and hospice nurse assessed; stating R1 hit their head and was bleeding from nose. At the time of incident, the facility did not call 911 to seek medical attention. Hospice nurse applied ice pack to affected area and R1 was checked every two to three hours.

Four days later on December 20, 2024, at 4:10pm, R1 was found lying on their back on Memory Care patio from an unwitnessed fall. Wellness Director (WD) noted R1 was bleeding from the back of their head. WD

(Continued on LIC 9099-C)

and MedTech cleaned head wound and contacted hospice. Hospice did not arrive to assess until 7:00 pm and recommended R1 be sent out to Emergency Room (ER). Hospice contacted R1’s POA, who requested to take R1 themselves via their private vehicle. R1 was not picked up by POA until 9:30pm, resulting in a 5 hour and 20 minute delay in medical services. Per the facility’s policy, non-emergency transport is only to be used when the resident needs urgent but non-emergency medical care. R1 being transported to the hospital by their POA violated the facility’s own policy. Per UCI Medical Records, R1 was admitted due to trauma and was evaluated by hospital staff. Findings include the following: left nondisplaced orbital floor fracture; maxillary sinus fracture; chronic dens fracture; C2 arch fracture; and laceration on right occipital area. R1 was discharged on December 25, 2024 back to the facility.

Quality Hospice records noted on December 20, 2024, that R1 sustained bruises on the left side of their face, a skin tear on left eyelid/eyebrow and an open wound on the occipital area. Notes reiterated fall precautions and staff monitoring while R1 ambulates. Prior to the falls, R1 was able to ambulate independently as R1’s care plan dated March 24, 2021, under Activities and Socialization, notes to “Encourage resident to participate in activities. Resident likes walking in courtyard, watching TV, or listening to music.” Based on evidence obtained, the facility failed to re-assess R1’s needs upon having a change in condition of their ambulatory abilities. As a result, R1 sustained ongoing falls with the last fall resulting in serious bodily injury requiring hospitalization.

Based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that: Lack of facility supervision resulted in resident sustaining serious injuries, Lack of facility care and supervision resulted in resident sustaining multiple falls and Facility staff failed to provide timely medical attention to the resident who was injured were substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

An exit interview was conducted with Ervin Nario, Health and Wellness Coordinator, and a copy of this report, 9099-D, LIC421IM and Appeal Rights were left at the facility.