Follow-up on corrections·April 19, 2024

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Met with staff Lizbeth Acuna, and explained the purpose for the visit. During an investigation conducted for a complaint dated: 3/18/22, it was discovered that Resident#1 (R1) sustained several documented falls at the facility during March 2022. Per hospice records, R1 fell at the facility on 3/01/22 and 3/20/22. Per facility incident reports obtained dated 3/03/22 and 3/20/22, facility reported to the Licensing agency that R1 sustained falls. Per R1's Physician's Report, Pre-Placement Appraisal, Needs and Services plan, and Current Appraisal, R1 was non-ambulatory and required two-person assist for transferring, but was able to propel self on her wheelchair. There was no indication that R1 was a fall risk. In the incident report and hospice notes dated 3/20/22, it was documented that R1 fell and sustained a laceration to the head that resulted in bleeding. Upon facility notifying hospice, the hospice physician ordered for R1 to be discharge from hospice and be sent to the hospital. After review of R1's records obtained, it was discovered that the facility failed to update the service plan for change of condition of R1, and not implementing interventions that led to additional falls resulting in the R1 sustaining a head laceration that required hospitalization. There was no recorded documentation from the facility or hospice indicating that the R1's Assessment/Needs and Services Plan was ever updated to reflect R1's fall risk/plan of care. Per California Code of Regulations, Title 22, deficiencies were observed and cited during today's visit. Exit interview was conducted and copy of this report and appeal rights were provided.