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 | Licensing Program Analyst (LPA) Rose Ruppert made an unannounced case management visit to follow-up on an Unusual/ Special Incident Report (SIR) received in our Regional Office on February 18, 2025. LPA was greeted and granted entry at 1pm by Staff #1. LPA met with Administrator (AD) Elena Weiner and explained the purpose of the visit.
LPA obtained the following for review: Current resident and staff rosters, Resident Identification and Emergency Information, Physician's Report and Preplacement Appraisal Information. LPA requested the staffing schedule for February 12, 2025; the date when the incident occurred. LPA also obtained hospital discharge paperwork.
LPA interviewed two of three staff members who witnessed the incident. Staff members stated that the incident was brief. Staff #1 had been in the resident's room and went to answer the door. Two other staff members were nearby when the resident began to slip from the bed. Resident does not have a history of falls. The resident tried to get up as the two staff members attempted to help resident and Staff #2 immediately called 911 and notified the family. Resident was sent out to the hospital for evaluation. The resident has returned to the community.
LPA interviewed the resident who stated she did not feel pain. She did not remember the events that transpired on February 12, 2025 but stated she is not completely fine; just okay. LPA reviewed the staffing schedule and noted there were two med techs and eight caregivers on-site at the time of the incident.
Based on the observations, record review and interviews made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Elena Weiner, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit. |