Follow-up on corrections·July 6, 2022

Licensing Program Analyst (LPA) Christine Wong made an unannounced case management visit to cite for deficiencies related to complaint investigation control # 28-AS-20210616095611. LPA met with Administrator Pamela Ogot and discussed the purpose of the visit. On the initial complaint visit conducted on 06/17/2021, a health & safety check of residents in care and tour of the facility and no safety hazards were observed. Staff and resident interviews were not conducted. Administrator Pamela Ogot provided LPAs copies of requested documents. The following documents were obtained: Resident #1-#3(R1-R3) file documents including Physician's Report , ID/Emergency Information, Appraisal Needs, Preplacement Appraisal Information, Function Admission Agreement and Incident Reports.. The complaint was accepted by the CCL IB investigation Unit, and assigned to IB Investigator Brian Slatic. IB investigator Brian conducted and complete investigation which includes interviews with the resident’s son/Health Care POA, facility administrator, five facility staff and Resident#1 (R1)’s former roommate. IB Investigator Brian also obtained Hospital Record, hospice documents and shower records. During the investigation, IB Investigator Brian reported that facility staff were aware of R1 was experiencing leg pain and swelling as early as the afternoon of June 3rd, 2021. On June 4th 2021, R1's primary physician also advised to get R1 to the hospital. However, the facility failed to get R1 to the hospital through Emergency Medical Services (EMS) or a non-emergency ambulance service until the morning of June 5th, 2021 which facility failed to get R1 timely medical care and when the fracture femur was finally diagnosed. 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.