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Inspection visit

complaint

TWIN PALMSLicense 1976068382 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

However, R1's file was not available and or missing and LPA was unable to confirm the name and contact information of the agency, frequency of the visits conducted, services provided, etc. LPA also conducted interviews with the Administrator, one (1) out of two (2) staff members and two (2) out of four (4) residents who were able to communicate. On 01/24/2024, LPA Panushkina Subpoenaed R1’s Medical Records. LPA received all requested Medical Records on 01/31/2024. Allegation: Resident sustained pressure injuries while in care The investigation findings revealed that Resident #1 (R1) had been living at this facility since September 18 th , 2023. Interview with the Administrator revealed that R1 was in bed, most of the time, and the facility staff would reposition R1 every 2 hours. Administrator informed LPA that R1 didn’t like to lay on a side and would always turn to his/her back. Interview with the Administrator also revealed that he was not aware of R1 having any pressure injuries until R1 was taken to the hospital on 01/09/24. Moreover, interviews with two (2) staff members confirmed that R1 had been repositioned every two (2) hours while living at the facility. Both staff members also informed LPA that no pressure injuries were observed on R1’s body. In addition, interview with S2 revealed that he/she provided bed-bath to R1 every day and on 01/09/24, right before R1 was taken to the hospital, S2 noticed a redness around R1’s coccyx area. Review of R1’s Medical Records revealed that R1 was admitted to the hospital (1 st time) on 12/22/23 and got discharged on 12/26/23. “Summary of Patient Progress” notes revealed that no skin injury was noted on R1 until 12/25/23 at 2:48pm. As for the type and location it was described as: blanchable redness on buttocks/sacrum/coccyx. Prior to re-admitting R1 back to the facility, facility staff failed to do a re-assessment for R1 prior to discharge on 12/26/23. Therefore, the Administrator failed to get R1 on Hospice, Home Health or obtain a Wound Specialist to address this issue. Subsequently, on 01/09/24, R1 was re-admitted to the hospital, and a review of hospital records revealed that R1 had multiple pressure injuries, from redness, various stage three (3) open injuries and one unstageable injury were discovered.Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting R1's serious bodily injury. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Deficiencies/civil penalty were issued per CA code of Regulations Title 22 on LIC-9099D Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87405(b)Type A

    87405(b) Administrator - Qualifications and Duties: (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.This requirement is not met as evidenced by: Based on the investigation, the Administrator did not comply with the section cited above, failing to follow and carry out an emergency policy, which poses/posed an immediate health and safety risk to residents in care.

  • 87411(d)(5)Type A

    87411(d)(5) Personnel Requirements – General: (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (5) Knowledge necessary in order to recognize... the need for professional help.This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility staff walked away and left a hot soup on an unstable table and failed to provide an appropriate supervision. Although, the staff was trained with all the required basic services, the staff did not immediately call 911. Instead, they contacted the Administrator who made a decision to wait for R1’s doctors appointment that was already scheduled on a 05/30/23 (5 days after the incident), which poses/posed an immediate health and safety risk to residents in care.

    Read full inspector narrative
  • 87463(a)Type B

    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...This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above. Adminsitrator confirmed that upon R1's discharge from the hospital on 12/26/23, R1's reappraisal was not updated, which poses/posed a potential health and safety risk to resident in care.

  • 87465(a)(1)Type A

    Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange... for medical and dental care appropriate to the conditions and needs of residents.This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above by providing care to R1 without hiring a Wound Specialist and or a medical professional from 12/26/23 to 01/09/24, which poses/posed an immediate health and safety risk to resident in care.

  • 87465(g)Type A

    87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health....This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the February 2, 2024 inspection of TWIN PALMS?

This was a complaint inspection of TWIN PALMS on February 2, 2024. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to TWIN PALMS on February 2, 2024?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87405(b) Administrator - Qualifications and Duties: (b) The administrator of a facility or facilities shall have the res..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.