Follow-up on corrections·January 13, 2023

Licensing Program Analyst (LPA) Christine Wong conducted a unannounced case management visit o cite for deficiencies related to complaint investigation control # 28-AS-20210616095611. LPA met with Administrator Barbara Tyler and discussed the purpose of the visit. On the initial complaint visit conducted on 12/20/2021, LPA conducted a health and safety check. LPA toured the facility with Denise Bartley and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. During today's visit. LPA also gathered information from Resident#1 (R1) file and reviewed two other residents' file. The following documents were collected which included: staff and resident roster, R1's resident information/emergency contact sheet, physician report dated on 10/12/21, preplacement appraisal information, physician/healthcare provider order sheet and care profile. The complaint was accepted by the CCL IB investigation Unit and assigned to IB Investigator Garcia. IB investigator Garcia conducted and complete investigation which includes interviews with the R1’s relative, six facility staff, facility residents, administrator, physical therapist. IB Investigator Brian also obtained Hospital Record and police report. During the investigation, IB Investigator Garcia reported that on December 11, 2021, R1 complained of right-side pain and pain across her chest area. R1 also attributed the pain to have occurred while the caregiver was assisted during her morning routine. The facility health and wellness director examined R1 and noted no bruising, swelling, redness to the area that R1 complained about. Facility did not seek any medical attention by a physician. (See LIC 809C for continuation) On December 12, 2021, R1 continued to complain of pain to the same area. On December 13, 2021, resident continued to complaint of the same pain to her right side and pain across the chest, especially when moving around. Facility staff called R1’s physician and requested PRN medication but staff never received any call back from R1’s physician. On December 15, 2021, R1’s home health nurse went to the facility to provide physical therapy for R1 and noticed R1 was complaining of chest pain. The therapist immediately called R1’s physician and advised to send R1 to the emergency room for evaluation. R1 was transported to the Emergency Room via 911 right away, and R1 was diagnosed with rib fracture and elevated potassium level. Per Title 22, Division, 6, Chapter 8 has been cited. See LIC 809D. Exit interview was held with Administrator. A copy of this report and appeal rights were provided.