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13 | AMENDED REPORT OF LIC9099A DATED 02/22/2024
On 03/01/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver amended LIC9099 report and deliver findings regarding the allegations listed above. LPA met with --- and explained the purpose of today's visit.
During the complaint investigation it was discovered that the resident had several documented falls - March 2022, February 2023, April 2023, and May 2023. On May 29, 2023 the resident had an unwitnessed fall, and based on interviews no one knew where the staff were and no staff were present to supervise the resident. The resident suffered significant injury which resulted in hospitalization and an arm separation was as a result of the fall. April 2023 fall the resident was evaluated at the hospital and released on the same day. After multiple falls in the facility there were no reappraisals done for the resident although the facility identified the resident as a fall risk. The facility failed to reassess the resident, establish, and update safety measures to prevent falls after sustaining these multiple falls to meet the resident's needs.
Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/02/2024
Section Cited
CCR
87463(a)(4) | 1
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7 | 87463 Reappraisals - (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This regulation has not been met as evidenced by: | 1
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7 | The licensee shall create a plan of correction to ensure that this regulation is met at all times. |
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14 | Based on the investigation the facility failed to reassess resident who was identified as a fall risk and develop a plan of care to prevent falls and meet the resident's needs. | 8
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Type A
03/02/2024
Section Cited
CCR
87468.2(a)(4) | 1
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities - (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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. This regulation has not been met as evidenced by: | 1
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7 | The licensee shall create a plan of correction to ensure that this regulation is met at all times. |
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14 | Based on the investigaiton the facility did not provide care and supervision to meet the needs of a resident who was identified as a fall risk and suffered a fall on May 29, 2023 that resulted in arm separation. There was no staff to supervise and was no where to be found. | 8
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