Carlton Senior Living Sacramento.

This LPA reviewed care notes for the resident (R1) from 02/02/25 - 03/31/25 and observed the following entries: 02/02/25, S2 logged, "Resident hearing aid put into charge" 02/03/25, S2 logged, "Resident hearing aid put into charger" 02/06/25, S2 logged, "Resident hearing aid put into charger" 02/09/25, S2 logged, "Resident hearing aid put into charger" 02/10/25, S2 logged, "Resident hearing aid put into charger" 02/17/25, S2 logged, "Resident surrendered the hearing aid to MT" 02/20/25, S2 logged, "Resident hear aid and gave to MT" 03/21/25, S3 logged, “Resident lost hearing aid in the right side of his ear" 03/22/25, S4 logged, "Resident did not have their hearing aid when MT went to collect them before bed" 03/31/25, S2 logged that they “took R1's "hearing aids and gave them to the MedTech to charge" According the responsible party for R1, their hearing aids were supposed to be charged every night. There are 58 days from 02/02/25 – 03/31/25. During that time period, care notes mentioned taking the hearing aids to charge a total of 8 times. There was no explanation as to why the hearing aids were not taken and charged on the other 50 days. There also was no documentation stating when, or if, hearing aids were returned to R1 in the morning. Two of the logs above mention that R1 lost or did not have their hearing aids on 03/21/25 and 03/31/25. In separate interviews with the Directors of Maintenance and Memory Care, both stated that hearing aids have been found in the laundry on more than one occasion. The Director of Maintenance also stated that the hearing aids are usually brought to him after they have been washed and before they have been transferred into the large capacity dryers in the Assisted Living Building. The Memory Care Director stated that the first place they look for missing hearing aids, is the laundry room. The Director of Memory Care also stated in their interview that the system they have in place now, where Medication Technicians or Care Partners take the hearing aids to recharge them at night and return them in the morning, must have come about after this complaint was filed and they realized they needed to have a specific procedure in place. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA reviewed the Individual Service Plan for R1 dated 9/27/24. This report stated, "Resident hearing needs will be known by staff, Speak slowly and clearly, get close to resident Remind resident to wear hearing aids." Under Frequency, it stated "Needed" and that these reminders were to be given by care partners. The report went on to state, "Check and see if hearing aids are in and working, Assist resident in applying hearing aids in the morning. Take out at night. Assistance provided by: Staff/At community Frequency: PRN /As Needed." It did not state where the hearing aids were to be put, if they were to be recharged, and when they were supposed to be taken or returned. LPA reviewed the resident's (R1's) service plan with an activation date of 2/26/26 and a last modified date of 4/16/25, the date this complaint was filed with Community Care Licensing. On page 3 of the Service Plan detail it stated," Hearing impairment- Resident's hearing needs will be known by staff. Speak slowly and clearly, get close to resident." The word care partner was next to this line to identify the person responsible for providing care. The service plan did not address the need for R1’s hearing aids to be charged or checked to ensure they were working properly. The second care plan provided less instruction than the first and did not allocate responsibility to anyone regarding these essential and expensive pieces of medical equipment. LPA requested the contact information for the responsible parties of 3 residents in memory care who utilize hearing aids. Two out of the three interviewed stated that their family members’ hearing aids were not charged regularly. Two of the three stated that they would visit, and their family member and they would not have their hearing aids in. Both families stated that their resident’s hearing aids had been lost on multiple occasions. If the hearing aids were lost, misplaced, or found in the laundry, then they were not being charged. Based on the documents reviewed and the interviews conducted, the standard for the preponderance of evidence has been met and the Department found "Staff do not ensure residents hearing aides are charged," SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A Case Management visit will also be conducted to address protecting the residents property (hearing aids) from being sent to the laundry. Regarding: Staff are not following incontinent care plan for resident. LPA reviewed R1's service plan with an activation date of 2/26/26 and a last modified date of 4/16/25. R1's LIC 602 stated that R1 had both bowel and bladder impairments. Under Continence Care: "Continence Care 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 - 60 min/day Staff will offer approximately 60 minutes of assistance per day while the resident uses the bathroom." LPA reviewed the Individual Service Plan for R1 dated 9/27/24. With regard to Continence Care the report stated the following: "Resident will be offered full assistance with toileting. Staff will offer approximately 60 minutes of full assistance while the resident uses the bathroom. Provided by Caregiver at the community. Frequency: Daily: Shift III - MC CP 2 NOC Shift I MC CP 7 AM Shift II MC CP 6 PM" In an interview with Hospice provider (H1), they reported that when R1 was visited in the morning by their staff for care, their adult briefs were "saturated." LPA requested notes from contracted care provider visits. The notes included the following logs: On 02/06/25, the log stated," Patient soaked form the waist down upon arrival." On 02/17/25, "provided bladder incontinent care." On 03/10/25,"Diapers and pants were saturated with urine." On 04/09/25, “Patient naked upon arrival, patient, bedsheet, underpants, and diapers wet with urine.” In an interview with staff, S8, they stated that the care plan was not always followed because they would run out for briefs for R1. Sometimes we would borrow them from other residents or from the storage closet, if there happened to be extra in there and if they had the right size. S8 stated "We did our best to keep R1 dry but R1 was one of the residents who would wake up in the middle of the night, sit up and walk to the bathroom even though we had changed R1. R1 would rip off their briefs because R1 had to urinate then they would run out of briefs." This LPA asked how R1 was running out of briefs and S8 stated that sometimes R1's briefs were taken for other residents who may or may not have been on hospice and didn't have enough. S8 stated that if another resident was on hospice we were told that it was OK for us to use other residents briefs that were also on hospice. S8 said that was why certain hospice supplies were running out for the specific residents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 S8 went on to state that "Even if R1 had 5-10 at any point. They were being used up at night because R1 would rip them off in R1's room and walk naked to the bathroom. Then when we would go and check on R1, I remember R1 would be sitting there and saying that they had to use the bathroom. “ Based on the review of documents and the interview conducted, the standard for the preponderance of evidence was met and the Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A Case Management Visit will also be conducted to address the shortage of incontinence supplies and the need to conduct reappraisal so that care plans are updated to address the needs of the residents in care. Regarding: Staff are not ensuring that resident laundry is being cleaned and returned to resident. Based on interviews with S5 and S7, clothing often goes missing in memory care. Residents wander into one another rooms and take things that may look familiar or that they simply want. S7 stated that Laundry is done 7 days a week - beds and linens are changed every day. No washers and dryers are used in memory care so everything is moved to the laundry room in assisted living. Residents' clothing are all washed in individual mesh bags so they stay together. S7 stated that 2 - 3 staff take the laundry to the laundry room where they have 8 washer and dryers. They work on the laundry until 5pm and then there is just 1 worker who finishes up, Everything gets returned the same day. S7's staff doesn't usually check pockets because memory care residents don't usually have valuables with them. If someone notices something bulky or jingling, they will remove it and return it or bring it directly to him. S7 also stated that they have found hearing aids in the laundry. They find them when switching clothes from the washer to the dryer. S7 stated that he takes the batteries out and puts the hearing aids in the room across from the laundry room (it is very hot) to dry out, and they "Usually work after that." LPA asked if he could think of a time when they did not work and S7 replied, "No." On 06/17/26, LPA Viarella visited rooms in the memory care community. LPA observed that only 1 in 3 of the rooms she visited 132, 135, and 142, only 135 had a mesh bag for their laundry. LPA took photos for documentation purposes. One did not have a mesh bag or liner and one had a plastic bag. LPA asked S5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 what was done with the clothes or bedding that were found and staff were not sure who they belonged to? S5 stated that they would bring all of these items out to the dining room and s

On 07/01/26, Licensing Program Analyst (LPA) Kimberly Viarella conducted a case management visit today to address the deficiencies learned through complaint investigation # 27-AS-20250416092323. This case management took place immediately following the delivery of the findings for the above complaint. LPA met with Memory Care Director/ Designee, Rose De La Garza. Residents' (R1 and R3) hearing aids were not safeguarded and were lost or destroyed. This deficiency was cited on the LIC 809D page. A reappraisal was not conducted for R1 when their incontinent care needs increased. Care plans for R1 and R3 also not reflect the need for residents to have assistance with charging and putting on their hearing aids. This deficiency has been cited on the LIC 809D page. The facility ran out of incontinent care products which directly impacted resident incontinent care. This deficiency has been cited on the LIC 809D page. LPA and the Memory Care Director discussed the deficiencies and corresponding plans of correction. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report along with APPEAL RIGHTS was provided and an exit interview was conducted with De La Garza.

Collateral interview with witness (P1) stated that on 2/3/26 at around 5:25PM they overheard Staff 3 (S3) yell the word “stupid” “why would you do that?” “you’re stupid”, “its so stupid”. Resident 1 (R1) was observed to face away from them in the hallway and it appeared they were trying to wheel their wheelchair way from S3. P1 stated they did not observe whether or not S3 handled R1 in a rough manner. Staff 1 (S1) and Staff 2 (S2) stated the facility did an internal investigation was initiated immidiatley on 2/3/26 which included reviewing video footage and interviews. The facility determined that S3 did not physically handle R1 in a rough manner. However, S1 stated the encounter observed does not meet the facilities’ standards. P1 stated S3 did not “yell” but they sounded frustrated and called them "stupid louder than regular speaking voice. It was determined by the facility that S3 did not treat R1 with dignity and respect, S1 stated this was an isolated incident in which no other staff has been observed not treat a resident with dignity and respect. S1 also stated preventative measures were taken prior to this incident and immediate measures were taken after the incident on 2/3/26 to ensure staff are trained on re-direction and resident's personal rights. S1 stated all staff including S3 received two days of dementia specific training focusing in redirection for individuals with wondering behaviors. S3 was immediately placed on leave on 2/3/26 and the investigation concluded on 2/10/26, in which it was determined S3's employment would no longer return to the facility. LPA reviewed video footage in which it was observed, in which it was corroborated that S3 was redirecting the resident out of room 139 and into the hallway. They pushed R1 down the hallway and released the wheel chair handle bars behind R1 simultaneously in which R1 proceeded to continue to wheel themselves down the hallway away from S3. S3 then turned away from R1 and opened the exterior door, it was reported there was someone knocking on the door and video footage confirms that S3 let the individual knocking into the facility. Video footage confirms S3 then proceeds to walk towards another hallway away from R3 and did not return to assist R1. In response to this incident, the facility held a mandatory meeting for all staff was held on 2/5/26 by S1 regarding Personal rights, expectations, positive approach, re-direction. An additional service was held on 2/4/26 called "Treating Residents with Kindness, Respect, and Professionalism". S1 reported that S3 was terminated as of 2/10/26 and has been disassociated from the facility. Based on interviews and record review of the LPA and review of records the allegation Staff yelled at resident is substantiated. Based on interviews and record review of the LPA and review of records the allegation Staff does not treat resident with dignity and respect is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1 and S2 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff 1 (S1) and Staff 2 (S2) stated the facility did an internal investigation which included reviewing video footage and interviews. LPA observed through video footage that S3 was assisting R1 out of another residents room, however there is no audio in the video footage. There is not enough evidence that S1 yelled at R1, was not a preponderance of the evidence obtained to corroborate the allegation "Staff yelled at resident", however it was determined that S3 did not treat R1 with dignity and respect on 2/3/26. S1 stated this was an isolated incident in which no other staff has been observed not treat a resident with dignity and respect. S1 also stated preventative measures were taken prior to this incident and immediate measures were taken after the incident on 2/3/26 to ensure staff are trained on re-direction and resident's personal rights. Interview with witness (P1) stated that on 2/3/26 at around they overheard. Staff 3 (S3) yell the word “stupid” “why would you do that?” “you're stupid”, “its so stupid”. Resident 1 (R1) was observed to try to wheel their wheel chair way from S3. P1 stated S3 spoke to R1 in an volume higher than a regular speaking voice. The facility was unable to determined if S3 yelled at R1 as there was only one witness however it is determined the incident likely did occur In response, the facility held a mandatory meeting for all staff was held on 2/5/26 by S1 regarding Personal rights, expectations, positive approach, re-direction. An additional service was held on 2/4/26 called Treating Residents with Kindness, Respect, and Professionalism. The incident was reported to authorized representative, licensing (LPA, Kimberly Villarella), long term care ombudsman. An incident report and SOC 341 was completed. Based on interviews and record review of the allegation "Staff yelled at resident" is UNSUBSTANTIATED There are no deficiencies cited regarding this allegation per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. Exit interview was conducted with the S1 and S2. Appeal Rights were issued, and a copy of this report was left at the facility.

It was discovered that the infested bedroom had not been included in the facility’s routine pest control services. The maintenance director added the room to the pest control list at the time of the inspection. Staff interviews revealed that photos of additional bugs had been submitted to management earlier, but no action was taken at that time. Additionally, a review of pest control invoices from October 2024 through March 2025 showed that services were limited to a single bedroom and focused solely on treating for German roaches. No pest control treatments or follow-up inspections were conducted in adjacent rooms during that period. Based on the information gathered, the licensee did not ensure that the facility adequately treated for pests. Allegation: Staff did not ensure resident was provided with bathing services It was alleged that facility staff failed to ensure the resident (R1) received appropriate bathing services. During the investigation, the Licensing Program Analyst (LPA) conducted staff interviews and reviewed facility records. Staff initially reported that R1 had stopped taking showers. The facility stated they had agreed with R1’s responsible party to continue offering showers in an effort to assist R1, prior to formally updating the care plan. Staff claimed that attempts were made to offer showers, but that R1 continued to refuse them. However, a review of R1’s shower logs revealed no documentation indicating that showers were offered or refused. When questioned further, staff acknowledged that showers had not actually been offered to R1, despite previous claims. Based on the evidence obtained, it was determined that staff did not ensure that R1 was provided with bathing services, as required. Allegation: Staff did not ensure residents room was kept in clean sanitary conditions It was alleged that staff did not ensure residents room was kept in clean sanitary conditions. During the investigation, LPA conducted observations to assist with this allegations. Based on observations made it was found during a facility visit on 03/27/2025 by LPAs Viarella and Hayes it was observed that there was pet feces and bugs all throughout the room. In addition, items were asked to be moved to inspect other items of the rooms because there was limited space to move through all the items places throughout the room. It was also observed that the sofa against the wall had bugs, boxes, and other items such as wrappers and bags stored behind it. During this visit, LPAs had to ask maintenance to help assist move the items to inspect throughout the room and behind the sofa. Based on the information gathered, the staff did not ensure residents room was kept in sanitary conditions. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An Exit Interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Personal rights violation. It was alleged that the facility had a personal rights violation. During the investigation and interview with 5 residents and 5 staff members were conducted. 5 out 5 residents report no issues with the staff or the facility at this time. 5 out 5 staff members deny that they violate any resident rights and are aware of their rights at the facility. Based on this information, there is not sufficient evidence to prove that the facility violated the rights of a resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

"at least 2 people to hold R1 up and steady, otherwise R1 sways back and forth. R1 has slid down onto the floor before because we can't keep R1 steady - their legs are weak." The third person is the one who actually cleans and changes R1. LPA asked why they didn't change R1 when R1 was horizontal in bed. S3 responded that they have tried that but, “R1 is very heavy and difficult to move, especially when R1 is sound asleep. R1 is dead weight then, and some of the care partners are more petite than others. With an average person, that might not be an issue but R1 is big and heavy.” LPA observed care notes in logs which state, at 12:35 AM, during the NOC shift, , “We were not able to stand the resident up with 3 care partners. The resident was deadweight and was not assisting. Resident was very weak and was not understanding instructions. We contacted the med tech for advice. Alpha One assisted with continent care. Resident is becoming too heavy to turn and stand. The last observation made regarding weight/condition was in July. We have not received any updates regarding this issue. This issue continued as documented by another care partner on 08/13/24 when they logged, “The resident was hard to do continent care and we call help from assisted living. We checked R1 4 care partners at the bed.” LPA observed that an updated service plan was added to ALIS for R1 on 08/15/24. LPA noted the following upon reviewing the care plan dated 08/07/24. LPA observed from a review of records that from December of 2023, to October of 2024, R1 gained 18 pounds. LPA reviewed documents including discharge paperwork from Kaiser. R1 had a rash and swelling in their groin area and they were diagnosed with a urinary tract infection. On page 2 the new plan stated that the, “resident’s risk for falling will be noted by staff.”  It went on to state, "the resident is encouraged to be out in the common areas during waking hours. Resident is encouraged to sit or lay down when feeling or staff sees resident fatigued.  Resident wears proper footwear when awake and walking (tennis shoes) resident is on toileting services. Staff are to check on resident approximately every 2 hours for toileting assistance. Staff are to redirect resident back to the common areas, if and when, available.”  LPA requested incident reports for R1. From 07/06/24 to 09/01/24, R1 had 1 witnessed and 4 unwitnessed falls. R1 was not getting their incontinent care needs met. R1's care plan should have been updated after the first fall to include a strategic fall prevention plan in order to prevent the following falls from occurring. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The standard for the preponderance of evidence has been met and the Department finds the allegation, "Staff are not meeting residents care needs." to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC9099 D page. A copy of this report was provided along with appeal rights and an exit interview was conducted.

R1 was found after staff received a phone call from SafelyYou, a service that detected that a resident had fallen in that room. R1 was taken to UC Davis Medical Center. R1 was noted to have a large hematoma to the right side of their forehead. R1 sustained multiple head bleeds including "significant worsening" of an old intracranial hemorrhage. On 5/30/24, R1 passed away. R1's cause of death was listed as Intraparenchymal Hemorrhage due to a ground level fall. Facility staff, S3, stated that they were assigned to R1 on 5/29/24. S3 saw R1 in the common area of the facility before S3 went on break. All other facility staff interviewed stated that they were either taking care of another resident, or they were not in the common area at the time of the incident. The facility was unable to provide a staff schedule indicating which staff were present in the common area. This LPA reviewed the Personal Care Interview conducted on 3/28/19. On page 3 it stated that R1 “needed minor help transferring” and on page 4 a check mark indicated that R1 was a FALL RISK. In the notes from a care conference on 3/25/20, Staff checked off that there were concerns for R1: balance/gait, FALL RISK, and concerns were also raised about wandering and exit seeking behaviors. On page 3 it stated that R1 had a history of falls and on page 4 it stated that R1 had fallen twice in the past year. On page 5 of this report, when asked if R1 had a history of wandering and exit seeking, “yes” was checked. Individual Service Plans indicated that R1 was a fall risk and that R1's wandering would be addressed accordingly. However, the plan did not list any specific strategy to mitigate R1's fall risk and wandering behavior. The Individual Service Plan was not updated after R1's fall in April of 2024 or after R1's fall on 5/28/24. It was updated on 5/30/24 after R1's fall on 5/29/24. The LPA observed the following upon reviewing the R1's re-assessment dated 5/30/24. On page 2 number 6, it was noted that R1 was a FALL RISK. On page 3, section 2, number 1, under "Functional Capabilities, Ambulation, and Transfers," the fact that R1 was a fall risk was not mentioned. There were two boxes checked off. One indicated that R1 used a walker independently and was able to get in and out unassisted. The second box indicated that R1 was not able to walk and that R1 used a wheelchair. In the notes section it stated, "NON-AMBULATORY: Resident ambulates herself utilizing their wheelchair and has a walker that 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 they can use to assist with transfers." Under section 2 it asked "Does the resident have any of these functional capability concerns?" Balance/Gait was checked but there were no notes provided or strategies listed under the notes section to address the concern. On page 6 question 6 asked, "Does the resident request or require ESCORT assistance to the dining room, activities, or anywhere (destinations) within community?" "Yes" was checked off to indicate that R1 needed assistance going to and returning from the dining room. Question 12 asked if R1 had fallen two of more times in the past year. "No" was checked off, which was incorrect; R1 had a documented fall on 4/21/24, another on 5/28/24 and the final fall on 5/29/24 which resulted in R1's death. R1 was sent out for evaluation for the first fall which resulted in a radius fracture. R1 was sent out for evaluation for the second fall as well. Because question 12 was answered incorrectly, the follow up questions were not answered. On page 7, as part of a fall risk assessment, staff were supposed to check off the appropriate box. Staff checked off that R1 had 1 fall within the last 3 months instead of the box that indicated R1 had 2 falls within the past 12 months. Page 9 also indicated that R1 had a history of exit seeking, a habit that, combined with being a fall risk would require increased checks. Upon reviewing the Individual Service Plan, this LPA observed that on pages 2 and 3, the plan indicated that R1 would receive round trip escorts by staff daily to R1's desired locations. The plan also stated that R1's "risk for falling would be noted by staff" and that staff were supposed to "note any changes in condition, balance problems or weakness, to supervisor." After the fall on 5/29/24, R1's care plan did not increase the frequency of checks on R1. Staff interviews revealed that the amount of time between resident checks varied amongst staff. S1 stated in an interview that when a resident returns from the hospital, they were put on alert charting and they were checked on every hour for 3 days. S1 went on to say that if a resident were a fall risk, they would be checked on every 10 - 15 minutes. S1 also added that most of the residents were in the common area and were "constantly" being checked on. S1 stated that R1 got the "standard" number of checks and did not require any additional checks or care. S2 stated that residents are checked on every 2 hours but if they have returned from the hospital, they were put on alert charting and checked every hour. S2 went on to say that R1 was checked on every 2 hours. Later during the same interview, S2 stated that R1 was on alert charting and being checked on every hour. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 S3 stated that residents were checked every 2 hours and that these checks were documented in the computerized system called ALIS. S3 stated that R1 required assistance with all levels of daily living activities. R1 utilized a wheelchair but would always try to stand up and get out of the chair on their own. Due to this, R1 was a fall risk. On 5/28/24 while the caregiver who was typically assigned to take care of R1 was on break, R1 attempted to get up on their own. R1 was in the common area and whoever is in the common area is responsible to supervise the residents. S2 stated that they did not know who was in the common area at that time, but R1 attempted to get up and they fell. R1 was sent out for evaluation at the hospital and returned the same day. It remains unknown as to who was supervising the residents in the common area that day. Those interviewed said that whoever was stationed there was responsible for supervising the residents. S5 stated that on 5/28/24, facility staff were having a team meeting, but that a staff person was in the common area watching the residents. S5 could not remember who was in the common area at the time. R1 attempted to transfer to a chair independently, fell, and hit their head. S5 also stated that it was common for residents to want to sit in a normal chair while eating in the common area. According to S5, facility staff were in the kitchen and the switch between shifts was taking place. Facility staff turned their head and when they looked back, R1 was falling. R1 was sent to the hospital and returned the same day. S6 stated that they were made aware of R1’s first fall on 5/28/24 by the Memory Care Director. The two reviewed video footage and saw R1 attempt to transfer from a chair back to their wheelchair. S2 saw R1 stand up, lose their balance, and fall. S6 said that facility staff were on their way to R1 when R1 stood up, but by the time they got there, R1 was on the floor. S1 stated that they did not know how no one saw R1 use their wheelchair to enter another resident’s room on 5/29/24. S1 stated they did not know who was watching the common area at the time. S1 added that it should be a team effort for who was watching the residents in the common area. S1 did not know who found R1 on the floor. S1 “definitely” believed that R1 should have had better supervision on 5/29/24. S4 stated that residents were checked on every two hours and that the residents mostly stayed in the common areas where they could be supervised by staff. S4 stated that R1 had a total of 5 falls at the facility and that R1 did not receive any extra supervision because the family would not pay for it. When asked who 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 was watching R1 when they fell on 5/28/24, S4 stated, "all of us." On 5/29/24, S4 stated that they think R1 fell when staff were getting lunch ready. They had an issue with another resident that pulled some staff away. S4 thought the fall could have been prevented, "If the staff saw R1 go into a different resident's room, they would have went in there and taken R1 out." When asked if they thought that the facility was understaffed, S4 said yes. "If there had been more people working, then there would have been more people watching the common area". S5 did not feel the facility was understaffed and believed that the residents were checked on every hour. S5 stated that if a resident were determined to be a fall risk, then they were checked on every thirty minutes. S5 was asked if R1 was supposed to be watched more closely since they just fell and went to the hospital the day before. S5 said "yes", R1 should have been on high watch. "It's not a policy, just common practice with them to watch them 24/7 after coming back from the hospital." S7 reported that R1 liked to wander after lunch. "It was like clockwork," S7 said, " R1 would wheel themselves around after lunch." S7 said that R1 was allowed to wander between their room and the common area. The records reviewed showed that as far back as 3/28/19, there were documented concerns regarding R1 being a fall risk. The report from 3/25/20 stated that R1 had 2 falls within the past year. The records reviewed showed that a comprehensive, strategic plan was not developed or communicated to the staff caring for R1. The functional assessment conducted had unanswered and incorrect answers included, which in turn, were used to calculate R1's fall risk. The staff di