Follow-up on corrections·April 18, 2025

On 4/18/2025 Licensing Program Analyst (LPA) M. Garza completed an unannounced Case Management visit. LPA met with Executive Director, Robert Huntley and explained reason for visit was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in rooms, common areas and in dining rooms. During a visit being conducted for a complaint on todays date, R1, R2 and R3 were observed by LPA. LPA observed R1 sitting in the hallway in Garden. R1 was observed with a large bandage on left shin area. Medical Technicians (MT 1 and MT 2) interviewed, it was stated R1 caught their leg on the side of their wheelchair (4/11/25) when getting up causing a skin tear. MT 1 stated "due to the tear looking infected R1 was seen by the physician". During review of charting notes, medical attention was sought 4/18/25. During review of Special Incident Reports this incident was not observed reported to CCL. R2 was observed sitting in the hallway near dining. R2 was observed with bruising under both eyes and a old bandage that was falling off on right elbow. During review of charting notes it was observed that R2 had 4 falls (3/27/25, 3/28/25, 3/31/25 and 4/5/25) where EMS services were contacted and transported R2 to the hospital for follow up. Interview with MT 2 disclosed that R2 was falling and was transported to hospital with a diagnosis of a UTI. Facility does not have a special incident report noting these falls/EMS being called/trips to the hospital. Facility did not report these incidents to CCL. R3 was observed coming out of Rm #410 with care giver. R3 was observed with wet hair and what appeared to be skin irritation needing to be looked at by a physician. MT 2 was unaware of the issue. A special incident report was not completed on this or reported to CCL. Deficiencies cited per Title 22. Exit interview completed with Executive Director, Robert. A copy of this report and appeal right provided.