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13 | On 12/1/23 starting at 10:30 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegation. AGPA met with Executive Director, Kiel Stromgren and explained the purpose of the visit.
During course of the investigation, the Department conducted interviews with facility staff, witnesses, and complainant. Documents include but not limited to: Physician’s Report, Resident‘s (R1) Assessment, Personnel Report (LIC 500), Incident Reports, Medication Administration Record (MAR), 24-hr Progress Notes, Medical Record, and Medication Clarification were obtained.
REPORT CONTINUES ON 9099C |
| Substantiated | Estimated Days of Completion: |
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32 | The Department investigated the allegations that the resident sustained a fracture while in care.
The Department concluded staff failed to acknowledge R1’s bruising surrounding his left shoulder prior to an office visit at Kaiser Permanente (KP) on January 13, 2022. The Department obtained a copy of R1’s discharge notes from KP where R1 was diagnosed with distal clavicle displaced fracture and soft tissue swelling. Photos obtained shows purple and yellow bruises that extended from the back below the neck, and to the left shoulder blades behind the left armpit. Bruising was also present in the front left shoulder. Based on interviews with 6 staff, 1 of 6 staff was the only one to have any knowledge of R1 sustaining an injury while at the facility. Staff (S6) observed R1’s shoulder being bruised, and other staff was not aware of what happened. R1’s physician’s report indicates resident needs assistance with bathing and toileting.
AGPA investigated the allegation that the facility failed to meet reporting requirements.
Based on record review of R1’s discharge notes from January 13, 2022, R1 was admitted to KP for neck pain and bruising on left shoulder from fall that occurred on January 9, 2022. There are no records of the Department receiving an incident report of R1’s fall.
AGPA investigated Resident’s care plan is inaccurate.
Based on a record review of R1’s care plan dated May 17, 2022, AGPA observed boxes under “assistive devices” were checked on the care plan form. However, during the interview with staff indicated R1 does not need an assistive device and can walk independently. The box on the form was checked off incorrectly.
Based on The Department observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are cited on the attached LIC 9099D.
Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/04/2023
Section Cited
HSC
1569.269(a)(6) | 1
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7 | 1569.269(a)(6) ENUMERATED RIGHTS; SEVERABILITY
(a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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7 | By POC date, Administrator agrees to review regulation with staff and submit self-certification letter.
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14 | This requirement is not met as evidenced by: Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above. Staff failed to have knowledge of R1’s bruising on R1’s left shoulder prior to R1’s visit to the hospital on January 13, 2022. Discharged notes obtained indicated R1 was diagnosed with distal clavicle displaced fracture and soft tissue swelling, and photo showed bruising on R1’s front and left back shoulder which poses an immediate health and safety risk to persons in care. | 8
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Type B
12/08/2023
Section Cited
CCR
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7 | 87463 REAPPRAISAL
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate....
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7 | By POC date, Administrator agrees to review regulation with staff and submit self-certification letter to CCLD. |
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14 | Based on record review and interview, Licensee did not comply with the regulation cited above by not providing accurate information on R1’s care plan dated 5/17/22. R1’s care plan indicated that R1 has an assistive device. However, no order for assistive device was observed and interviews with staff revealed R1 does not use assistive device and can walk independently which poses a potential health and safety risk to persons in care. | 8
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Deficiency Type
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Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/08/2023
Section Cited
CCR
87211(a)(1) | 1
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7 | 87211(a)(1) REPORTING REQUIREMENTS
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. | 1
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14 | This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited and failed to submit an incident report to CCLD of R1’s fall. The fall resulted R1 being admitted to the hospital and sustaining distal clavicle displaced fracture and soft tissue swelling which poses a potential health and safety risk to persons in care.
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13 | On 12/1/23 starting at 10:30 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegation. AGPA met with Executive Director, Kiel Stromgren and explained the purpose of the visit.
During course of the investigation, the Department conducted interviews with facility staff, witnesses, and complainant. Documents include but not limited to: Physician’s Report, Resident ‘s (R1) Assessment, Personnel Report (LIC 500), Incident Reports, Medication Administration Record (MAR), 24-hr Progress Notes, Medical Record, and Medication Clarification.
REPORT CONTINUES ON 9099C |
| Unsubstantiated | Estimated Days of Completion: |
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32 | Allegation: Personal Rights – Resident sustained multiple injuries while in care.
Based on record review of R1’s incident report, R1 smashed R1’s left pinky on 2/21/22, and sustained a skin tear on right elbow on 7/16/22. However, both incidents were unwitnessed, and according to R1’s assessment, R1 does not need 1 on 1 care. On 2/21/22, R1 was admitted to the hospital and was treated with stitches for R1’s left pinky.
Allegation: Staff are not following a licensed physician’s orders for a resident
Based on information obtained by complainant, R1 is being administered psychiatric medication and has an assisted device without a doctor’s order. AGPA reviewed R1’s Medication Administration Record, and did not observe psychiatric medication listed on the MAR. In addition, AGPA reviewed R1’s doctor’s order, and did not observe an assistive device. According to an interview with staff by the Department, R1 does not use an assistive device and can walk independently.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violatiosn did or did not occur, therefore the allegation are UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided to Executive Director. |