NARRATIVE |
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
26
27
28
29
30
31
32 | On 11/3/2021, from 1:07 p.m. to 3:40 p.m., LPA Camara conducted the initial 10-day complaint visit. The LPA met with licensee/administrator Charisse Bradley and explained the reason for the visit. During the visit, LPA conducted a brief facility tour at 1:10 p.m., interviewed the licensee at 1:18 p.m., interviewed Staff 1 (S1) at 1:54 p.m. and reviewed and obtained pertinent documents starting at approximately 2:23 p.m. On 2/9/2022, from 1:52 p.m. to 5:23 p.m., LPA Camara conducted a subsequent complaint visit to the facility while also conducted an annual inspection. LPA met with the licensee again, reviewed records for any newly obtained documents, and interviewed Staff 2 (S2) at 1:59 p.m.
A review of the facility file for R1 revealed that R1 was admitted to the facility on 10/1/2021. However, the licensee never obtained a medical assessment (LIC 602A) prior to admitting R1. LPA found in R1’s facility file a medical note dated 9/23/2021 with a list of medications and medical conditions from one of R1’s physicians, however there was nothing indicating R1’s needs in the medical note. The list of medical conditions on the note included “fall risk”; it was the first condition listed.
During LPA’s interviews with S1 and S2, both staff stated they were not aware R1 was a fall risk. The licensee told LPA that R1 was “not really a fall risk”, so she did not take extra precautions such as a bed or chair alarm. The licensee confirmed that from the date of R1’s admission to the facility, R1 had a home health physical therapist provide physical therapy at the facility. The licensee stated she did not know what condition R1 was receiving physical therapy to treat.
Both S1 and S2 stated they would assist R1 with transferring from a chair to R1’s walker. However, both staff stated if they did not have eyes on R1, then R1 was capable of getting out of a chair on their own and R1 would sometimes forget to use their walker if staff were not there to remind R1.
Both staff confirmed that on 10/31/2021 at approximately 8:00-8:30 p.m. R1 was seated in the living room watching television while both staff were in the adjoining kitchen when they heard a noise. Staff went to investigate and found R1 sitting on the floor at the bottom of the ramp which leads from the living room to the kitchen/dining room area. There were differing accounts as to whether R1 had their walker or not. Both staff
(continued on 9099-C) |
NARRATIVE |
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
26
27
28
29
30
31
32 | stated R1 was carrying two glasses of water when the fall occurred. Both staff helped R1 up into a wheelchair and took R1 to their room. S1 applied ice to R1’s leg while S2 called 9-1-1. R1 was taken to the hospital and required surgery to repair fractures to R1’s hip.
On the allegation - R1 sustained a fracture while in care due to neglect/lack of supervision - both staff stated they were not made aware that R1 was a fall risk and the licensee stated she did not think R1 was a fall risk, despite having documentation in file from a physician stating such and R1 receiving ongoing physical therapy at the facility. In addition, the licensee failed to obtain a required medical assessment prior to admitting R1 to the facility. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation R1 sustained a fracture while in care due to neglect/lack of supervision, is Substantiated at this time.
On the allegation - Staff did not provide activities for resident – S1 and S2 both stated the facility did not have activities for R1. S1 stated they would do puzzles at the dining room table or toss a beach ball for activities with residents, but R1 would get confused. S2 stated the facility had games and cards to play but R1 was too confused to participate in those activities. The licensee stated that pre-covid they would take residents to the local city operated senior center for activities, however the senior center had only just recently re-opened and they had not gone back yet. In addition, the licensee said the activities at the senior center were not always appropriate for residents with dementia. Based on the information obtained during the staff interviews, R1 was not provided with appropriate activities for R1’s cognition level, therefore the allegation staff did not provide activities for resident is Substantiated at this time.
A $500 immediate civil penalty is assessed today. The co-administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
02/24/2023
Section Cited
CCR
87464(f)(1) | 1
2
3
4
5
6
7 | 87464(f)(1) Basic Services.
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).
This requirement is not met as evidenced by:
| 1
2
3
4
5
6
7 | Licensee will submit a plan to ensure proper care and supervision is being provided to the residents. Submit to CCL by 2/24/23. |
 | 8
9
10
11
12
13
14 | Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided proper care and supervision to prevent falls which resulted in R1 sustaining a fractured hip due to a fall at the facility, which posed an immediate health and safety risk to residents in care. | 8
9
10
11
12
13
14 | An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1) |
Type A
02/24/2023
Section Cited
CCR
87458(a) | 1
2
3
4
5
6
7 | 87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. | 1
2
3
4
5
6
7 | Licensee will submit a plan to ensure all required documents are obtained prior to admitting a resident into the facility. Submit to CCL by 2/24/23. |
| 8
9
10
11
12
13
14 | This requirement is not met as evidenced by:Based on interviews and records review, the licensee did not comply with the section cited above. The licensee failed to obtain a medical assessment outlining R1’s physical limitations and care needs prior to R1’s admission to the facility, which resulted in staff being uninformed of R1's fall risk and | 8
9
10
11
12
13
14 | ultimately R1 suffered injury due to a fall at the facility, which posed an immediate health and safety risk to residents in care. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
02/24/2023
Section Cited
CCR
87219(a) | 1
2
3
4
5
6
7 | 87219 Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | Licensee will submit a plan to ensure the facility provides appropriate activities for all residents at the facility. Submit to CCL by 2/24/23. |
| 8
9
10
11
12
13
14 | Based on interviews with staff, the licensee did not comply with the section cited above. The licensee failed to provide appropriate activities for R1, which posed a potential health and safety risk to residents in care. | 8
9
10
11
12
13
14 | |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |