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25 | Licensing Program Analyst (LPA) Angela Hood arrived unannounced today, 5/23/24, and met with the Administrator, Persida Pop, to conduct a case management visit regarding information obtained during a complaint investigation, #59-AS-20240112110717, that was completed on 5/23/24.
Emergency Medical Services (EMS) Prehospital Care Report dated 12/28/23 indicated that EMS was dispatched to the facility due to the owner reporting that resident (R1) was having chronic diarrhea for 3 weeks and new weakness. EMS report indicated that R1’s Power of Attorney (POA), R1, Administrator, and care staff stated that R1 was unable to self-administer insulin that evening, due to weakness.
Interview with the Administrator indicated that they had a meeting with R1’s POA and physician by phone regarding chronic diarrhea and not eating. Administrator indicated that R1 was not receiving hospice services and was declining. Administrator indicated that R1 is not able to self-administer insulin during the PM shift. Care notes provided by the facility for the month of December 2023 did not indicate any instances of R1 having diarrhea or not being able to self-administer insulin.
During the investigation, the Department requested documentation for all incidents where EMS were contacted regarding R1, any communications between the facility and R1’s physician, and incident reports pertaining to R1. Communication with the Administrator indicated that they did not contact R1’s physician and only reached out to the family and home health nurse. The Department requested documentation with correspondence between the facility and R1’s family and home health nurse. To date, the facility was unable to provide the requested documentation.
Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 809-D page.
Exit interview was conducted. A copy of this report and appeal rights provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
05/24/2024
Section Cited
CCR
87466
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7 | 87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by:
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7 | Licensee agrees to complete a statement of understanding regarding observation of residents and create a plan to ensure all changes in residents’ conditions are documented and that their physician and responsible party are notified. Licensee will submit statement and plan to LPA by POC due date of 5/24/24. |
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14 | Based on records reviewed and interviews conducted, the facility observed changes in R1’s condition and did not document such changes or bring changes to the attention of R1’s physician or responsible party, which poses an immediate health, safety, and personal rights risk to residents in care. | 8
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Type A
05/24/2024
Section Cited
CCR87465(a)(1)
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7 | 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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7 | Licensee agrees to create a plan to ensure that, when a resident has a change in condition, the facility will arrange or assist in arranging appropriate medical care.
Licensee shall submit to LPA by the POC due date of 5/24/24.
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14 | Based on records reviewed and interviews conducted, the facility observed R1’s change in condition and did not seek medical attention timely, which poses an immediate health, safety, and personal rights risk to residents in care. | 8
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