-On 09/01/2024 at approximately 1958 hours, R1 was found on the floor lying on her right side on the fall mat. She complained of pain to her shoulder and right side of hip. No other injuries were visible. She was assisted to her bed and provided with pain medication.

-On 06/03/2024 at approximately 2245 hours, R1’s bed motion sensor went off and R1 was found on the floor curled up on her left side. She had a large skin tear and complained of pain. R1 was transported to the hospital to be medically assessed.

-On 05/10/2024 at approximately 2200 hours, R1 was found lying next to her bed. An assessment was completed, and no new injuries were located. R1 was assisted back to her bed.

-On 03/22/2024, at approximately 1530 hours, R1’s bed motion sensor went off. R1 was found sitting on the bathroom floor. No injuries were noted. R1 was assisted onto her wheelchair and brought to the main lobby.

-On 02/26/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks next to her bed. She was confused and disorientated. Staff attempted to place R1 back in her bed. However, R1 refused to. R1 attempted to stand up frequently despite the staff’s redirections. R1 was brought to the common areas for closer staff supervision.

On 03/22/2024, R1 was admitted to an acute hospital regarding a fall she suffered at the El Rio facility. A medical assessment was completed, and R1 was found to have a fracture on her left wrist.

During the course of a interview with a former staff member that is a Licensed Vocational Nurse (LVN), the LVN stated that the facility is understaffed and the staff are overworked and if the facility had the proper staff to client ratio, some of these incidents could have been prevented if staff had the time to conduct appropriate checks on the residents. The LVN said even though staff checked the staff log indicating they had checked on a resident, such as R1, the interviewee believed some staff did not conduct their hourly checks on time based on the amount of work and responsibilities they had. The LVN also said she believed R1 was dehydrated because staff did not have time throughout the day to encourage R1 to drink her liquids. The LVN said the reason she stopped working at the El Rio facility was due to the facility being poorly managed, understaffed, the staff being overworked and unable to provide the proper care and supervision for the residents.

Allegation 1: Resident sustained multiple falls in the facility resulting in multiple injuries

Resident 1 (R1) suffered approximately 9 unwitnessed falls while in care at the El Rio Memory Care facility, some resulting in fractures. Facility staff reported R1 was prone to falling due to R1’s mental and physical condition. To prevent or diminish the number of falls, facility staff indicated they provided R1 with a half-rail bed, a motion-sensor bed adjusted to higher sensitivity, a “fall mat” and constant staff supervision. Most of the staff reported R1 was to be checked every hour. The staff Hourly Check log indicates these checks were conducted every hour or longer. However, R1’s Facility Service Plan and Resident Assessment indicate R1 required staff checks every 30 minutes. Staff reported that for a few months, the facility was short-staffed and unable to complete all the tasks and provide proper resident care and supervision, including 30-minute checks. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means the preponderance of evidence standard has been met.

On 05/04/2024, R1 suffered an unwitnessed fall for which required hospitalization. A medical assessment was completed, and R1 was diagnosed with acute kidney injury due to severe dehydration. An ‘acute’ illness means the illness developed recently. Facility staff reported R1 ate most of the meals given but refused to drink all the water provided. Some staff said that throughout the day they provided residents with water and encouraged them to drink it. However, other staff reported that for a few months, the facility was short staffed, and they were unable to complete all the tasks and provide proper resident care and supervision. This included encouraging residents, such as R1, to drink their water throughout the day. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means the preponderance of evidence standard has been met.

Allegation 3: Staff did not follow resident’s care plan.

Facility staff reported R1 was prone to falling due to R1’s mental and physical condition. Most of the staff reported R1 was to be checked every hour. The staff Hourly Check log indicates these checks were conducted every hour or longer. However, R1’s Facility Service Plan and Resident Assessment indicate R1 required staff checks every 30 minutes. Staff reported that for a few months, the facility was short staffed and unable to complete all the tasks and provide proper resident care and supervision, including 30- minute checks. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code. Civil penalties are also being assessed in the amount of $1500.00. At this time civil penalty assessments are under review and additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49. An exit interview was conducted and a copy of this report was given to Executive Director Theresa Pettapiece.