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32 | The nurse reported R1’s condition to R1’s son. R1’s son then instructed Administrator to send R1 to the hospital to get checked on 6/5/2023. R1 went to a skilled nursing facility upon discharge from the hospital and did not come back to the facility.
R1 moved to the facility on May 1, 2023 and moved out on June 7, 2023.
A review of email conversations between Administrator and R1's son indicate the Administrator informing R1’s son that R1 does not have any fracture. And that the hand is not swollen. The administrator also states the reason could be that R1 was taking some part of the bed and has broken pots in the room. The Administrator states, “In the future, I will make sure the care staff calls you and update you regarding any decline.”
A review of R1’s medical records and photo provided to CCL indicate R1 sustained bruises on both arms and a cut on the left bicep. During the interview with Administrator and Staff 1 (S1), both state R1 did not incur any fall. Administrator and S1 state R1 probably got the bruises and cut when R1 was exhibiting aggressive behavior such as crawling under the bed, throwing pots and trying to pull down picture frames.
Based on record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors.
Based on LPA interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D.
Exit interview was conducted with Meeran. Appeal Rights was provided.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Deficiency Dismissed
Type B
08/23/2023
Section Cited
CCR
87705(b)(1) | 1
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7 | 87705 (b)(1) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
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7 | The administrator will review facility’s plan of operation regarding procedures for notifying the resident’s physician, family members, or conservator when a resident’s condition or behavior changes. Administrator will submit to CCL self-certification of understanding by POC date. |
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This requirement is not met as evidenced by:
Based on interviews and record reviews conducted, facility did not notify R1’s Responsible Person on R1’s change in condition which poses an immediate risk to health and safety of clients under care.
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Deficiency Dismissed
Type B
08/30/2023
Section Cited
CCR
87705(b)(2) | 1
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7 | 87705(b)(2) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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7 | The administrator will review all residents Physician’s Reports and update Appraisal Needs and Services Plan addressing resident behaviors such as wandering and aggressive behavior. Administrator will send copies of updated care plan by POC date.
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14 | This requirement is not met as evidenced by:
Based on interviews and record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors. Administrator and facility staff interviewed state R1 was observed crawling under the bed, throwing flowerpots inside the room and pulling down picture frames on the wall.
Despite observing R1’s aggressive behaviors, the facility did not provide safety measures to prevent R1 from sustaining bruises on both arms and a cut on R1’s left biceps which poses an immediate threat to the health and safety of clients under care.
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