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13 | Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. LPA met with Interim General Manager, Kippie Castronovo.
On 08/28/2023, the Department received a complaint alleging that a resident (R1) was severely neglected resulting in injuries after sustaining a fall and was found on their apartment floor covered with ants. On 08/30/2023, the initial complaint investigation was conducted.
The following documents were obtained to include resident (R1)’s medical records, physician’s report, service plan, progress notes, admission agreement, staff schedule from July 30, 2023 to September 2, 2023, and resident check-ins. PAGE 1 OF 3. |
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On 08/08/2023, R1 was admitted to the hospital after a fall. The review of R1’s medical records noted that R1 was not safe to go back to the facility. R1’s active problems included impaired mobility and activities of daily living and muscle weakness. However, since R1 refused to go to a skilled nursing facility R1 was referred to Home Health. On 08/18/2023, the hospital case worker spoke with two staff at the facility and advised of the discharge and referral to home health.
On 08/19/2023, R1 was discharged back to the facility. Based on the facility's protocols, resident was placed under alert charting for return from hospital and staff were to monitor R1 for 72 hours. Based on staff interview, 6 out of 6 staff stated that R1 was independent. Staff was unaware that R1 was on a 72-hour check and stated that staff was not checking on R1 as they were supposed to. Based on record review, there is only documentation that staff noted R1’s condition on 08/19/2023 and 08/21/2023. There is no documentation that R1’s condition was monitored on 08/20/2023.
During staff interviews, it was also observed that R1 was not feeling well on 08/24/2023, however, there was no documentation of communication between staff nor of R1’s condition that day.
On 08/27/2023, at 0750 hours, staff found R1 on his/her bedroom floor with dried blood and injuries to his/her body including a golf size bump on his/her forehead. Staff called 911 and R1 was transported to the hospital where it was noted that R1 had a bump on his/her forehead with redness and discoloration on the right side of his/her right eye, skin tear on his/her right elbow and on his/her hands and knees.
Based on interview, R1 reported to be getting ready for bedtime, when R1 fell and hit his/her head on the night stand. R1 was on the floor and tried calling out for staff help, however, no one responded. R1 was not checked by the staff throughout that night and was found the morning of 08/27/2023 after calling out for help.
Based on staff interview, when R1 was found on the floor, R1 had ants on his/her body. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
01/17/2024
Section Cited
CCR
87466 | 1
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7 | 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 evidence by: | 1
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7 | Licensee will provide an in-service training for all staff to include the topic of observations and documenting resident's conditions and monitoring resident's for 72 hour checks. Licensee will submit the training documentation to LPA by POC due date of 01/17/2024. |
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14 | Based on interview, record review, and observation the licensee did not ensure resident (R1) was checked on regularly for 72 hours after being discharged back to the facility from the hospital. On 08/27/2023, resident was found on the floor with injuries to include a golf size bump on the forehead and skin discoloration on the eye, elbow, hands and knees. This poses/posed an immediate health, safety, and personal rights risk to persons in care. | 8
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14 | Licensee will also submit a plan to provide an all-staff training for the remainder of the staff who are not present today. Licensee will submit the plan to LPA by POC due date. |
Request Denied
Type A
01/17/2024
Section Cited
CCR
87468.1(a)(2) | 1
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7 | (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: | 1
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7 | Licensee will provide an in-service training on topics to inlcude sanitation, cleanliness, and resident's health and safety. Licensee will submit the in-service training to LPA by POC due date of 01/17/2024. |
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14 | Based on interview, record review, and observation the licensee did not ensure resident (R1) was accorded a healthful and comfortable accommodation due to being found on the floor with ants on R1’s body which poses/posed an immediate health, safety, and personal rights risk to persons in care. | 8
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14 | Licensee will submit the facility's pest control contract to include any documentation on the ants issue. Licensee will submit the documentation to LPA by POC due date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
01/17/2024
Section Cited
CCR
87463(a)(3) | 1
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7 | (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 … This requirement is not met as evidenced by: | 1
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7 | Licensee will provide an in-service training with the facility's directors, team nurses, and care staff to go over re-appraisals when the resident returns to the community. Licensee will submit the in-service training to LPA by POC due date of 01/17/2024. |
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14 | Based on interview, record review, and observation the licensee did not ensure resident (R1)’s reappraisal was accurate and documented R1’s diagnosis and changes to the resident’s condition after returning to the facility from the hospital on 08/19/2023 which poses/posed an immediate health, safety, and personal rights risk to persons in care. | 8
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