Regarding the allegation of Staff did not adequately supervise resident who is a fall risk. LPA reviewed records, made observations and conducted interviews. Based on records review, resident’s (R1) Physician Report (LIC602) dated 1/28/20, R1 had a diagnose of dementia. Special Incident Report dated 10/6/20 submitted by Administrator indicates that “staff would have resident sit in an area where resident could be visually monitored” which it was also determined in R1’s Needs and Services Plan dated 3/9/2020, R1 was a fall risk person that required to be seated in areas where they can be easily observed by staff. Based on confidential interviews conducted on 1/28/21 and 2/8/21 with staff, R1 had an un-witnessed fall (by facility staff) while staff were changing shifts in the main office. Reporting party provided information that non facility staff had to bang on main office window in order to get staff attention to assist R1 after the fall. Therefore, Facility failed to ensure that R1 was adequately supervised by staff. The preponderance of evidence standard has been met; therefore, the above allegation of Staff did not adequately supervise resident who is a fall risk is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.

Regarding allegation of resident died as a result of a serious fall at the facility. LPA reviewed records and conducted interviews. R1 had an unwitnessed fall (by staff) on 10/2/2020, R1 was a known fall risk person by needs and services plan dated 3/9/2020. Facility failed to seek timely medical & provide adequate supervision in. Per Special Incident Report submitted to CCL, R1 was sent out on 10/2/20 to the Hospital and returned to facility on 10/6/20, medical records determined injury brain bleed from the fall. R1 passed away on facility on this date. Based on records review obtained for R1, death certificate issued on 10/26/20 revealed that immediate cause of death is Intracranial hemorrhage, R1 injuries resulted in death. Although death certificate indicates that R1 had dementia and seizures. The preponderance of evidence standard has been met; therefore, the above allegation of Resident died as a result of a serious fall at the facility is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.

Regarding allegation of Staff failed to assess resident change of condition after fall. Reporting party alleges that four staff came over to assess R1 while they were unresponsive. One of the staff brought R1’s wheelchair, Other staff hold R1 by their right arm and pulled it in an upward direction trying to pull by their arm while R1 was unconscious. Other staff stopped staff and they together lifted R1 into the chair, took R1 to their room and laid R1 in their bed. Staff (S1) propped an ice pack on R1’s head and left there unattended. Licensee arrived later and inquired about the decision of not taking R1 for medical care, he asked S1 if they had checked range of motion and staff could not answer why not then Licensee determined to call 911. LPA review records provided by facility and conducted interviews with (S1) on 1/28/21 indicated that S1 called Administrator who was not present at the time of incident then conducted range of motion, assessed R1 and applied cold ice to their bump. Per incident report submitted to CCL indicates that S1 checked on R1 for injuries, saw that R1 hit their head, took R1 to laid down, put some ice on R1’s head, called responsible party after monitoring R1 but it was Licensee who determined to call 911 to transfer R1 to the Hospital approximately 53 minutes after the fall. Facility staff failed to observed change of condition. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.