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25 | Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - deficiencies visit based on violations observed during 2 complaint investigations for complaint control number 26-AS-20221215152806 and 26-AS-20230714114133. LPA met with General Manger, Billy Mitchell and Resident Care Director, Jocelyne Bailon Solache.
During the investigation for complaint control number 26-AS-20221215152806, it was found that on 07/09/2021, R1’s service plan was updated due to a change of condition in which R1 was moved from assisted living to memory care. On 04/07/2022, R1’s level of care increased from level 1 to level 2, which stated R1 was a low potential for falls to moderate potential for falls. On 04/29/2022, R1 went from a moderate potential for falls to a high potential for falls. On 11/23/2022, R1’s level of care increased from a level 2 to a level 10. Based on record review, resident (R1) did not obtain an updated physician’s report after any changes of conditions based on the re-evaluations and updated service plans. R1's physician's report was dated on 02/11/2021. R1 was admitted to the facility on 02/28/2021.
R1’s service plans dated 07/08/2021, 04/07/2022, 04/29/2022, 09/09/2022, and 11/12/2022 were not signed by R1 and R1’s responsible party. The facility was unable to produce documents or proof to show the service plans were reviewed with R1’s and R1’s responsible party.
On 04/30/2022, 06/24/2022, 07/05/2022, 07/06/2022, 08/09/2022, 09/23/2022, 10/07/2022 R1 sustained falls. Based on record review, it was not noted or indicated that R1’s physician was notified of the falls. SEE LIC809-C. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/14/2024
Section Cited
CCR
87465(a)(1)
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7 | (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 was not met as evidenced by: | 1
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7 | Licensee will be implementing a high-risk meeting weekly with the leadership team to ensure processes are being followed. Licensee will submit a statement of understanding of the section (87465(a)(1)) to LPA |
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14 | Based on record review and observation, the licensee did not ensure to obtain an updated physician’s report for resident (R1) after staff observed changes in R1’s conditions based on the re-evaluations and updated service plans, and did not obtain follow-up with R1's physician in a timely manner for an order for R1's nutritional beverage which poses a potential health, safety and personal rights risk to persons in care. | 8
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14 | Dolores via email by POC due date of 10/14/2024. |
Type B
10/14/2024
Section Cited
CCR87463(c)
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7 | (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by: | 1
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7 | Licensee will submit a written plan of the facility's process in ensuring the needs and services plans are reviewed and signed with the resident and/or their responsible parties. |
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14 | Based on record review and observation, the licensee did not ensure to review R1’s updated service plans with R1’s responsible party which poses a potential health, safety and personal rights risk to persons in care. | 8
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14 | Licensee will send the written plan via email by POC due date of 10/14/2024. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/14/2024
Section Cited
CCR
87563(b)
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7 | (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not met as evidenced by: | 1
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7 | Licensee will conduct a internal audit to ensure resident's physician's are being notified of any changes of conditions and to review the facility's process in ensuring physician's are being notified of any changes of conditions. |
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14 | Based on record review and observation, the licensee did not ensure to report R1’s falls to R1’s physician on 04/30/2022, 06/24/2022, 07/05/2022, 07/06/2022, 08/09/2022, 09/23/2022, 10/07/2022 which poses a potential health, safety and personal rights risk to persons in care. | 8
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14 | Licensee will submit a written result of the internal audit to LPA Dolores via email by POC due date on 10/14/2024. |
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