Follow-up on corrections·December 16, 2025

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced case management visit to the facility. LPA Haddadin was greeted and granted entry by Administrator (AD) Weiner Elena . The purpose of the visit was to address deficiencies identified during the investigation of complaint #22-AS-20250417112836. The following deficiencies were observed: Per hospice records, between October 2023 and April 2025, R1 sustained at least nine documented falls. The earliest occurred on October 29, 2023, when R1 fell while attempting to transfer from bed to wheelchair. On November 2, 2023, Hospice record also showed that R1 had a skin tear to the left elbow. Facility had no records documenting regarding the falls or the skin tear . R1 sustained a second fall on November 8, 2023, and complained of left hip pain. R1 was transferred to Kaiser Hospital and diagnosed with left intertrochanteric femur fracture and underwent surgical repair the following day. R1 was later transferred to Post Acute Care for Rehabilitation. The facility’s internal self-report reflects the fall entry was not documented until November 29, 2023. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. On December 17, 2024, R1 complained of knee pain and swelling which was reported by the facility Med Tech to Vitas Hospice nurse. The visiting nurse prescribed Tylenol for R1’s pain and instructions to staff to monitor the swelling and contract hospice if needed. {***CONTINUE***809C} On December 26, 2024, R1 was observed to still have left knee swelling by the hospice doctor, however, facility staff denied R1 sustaining any fall. A subsequent X-ray completed on December 27, 2024, by Pacific Coast Mobile Radiology confirmed a complete transverse fracture of the distal left femur, resulting in a ten day delay of diagnosis and treatment of R1’s injuries. On February 19, 2024, hospice documented that R1 was a high fall risk and uncooperative with transfers. On June 27, 2024, Hospice again documented that R1 was a high fall risk. Despite this, updates to the facility’s Needs and Services Plans dated May 18, 2023, May 18, 2024, and March 10, 2025, did not address R1’s increased needs of supervision. The facility did not revise the plans as required to reflect R1’s high fall risk and need for closer supervision and assistance. Furthermore, between October 2023 and April 2025, the facility reported only one fall incident to Community Care Licensing, which was received on April 25, 2025. A search of the SIR portal system confirmed that no other fall incidents were reported during this period. Based on record review, the following are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, confidential names list and appeal rights were provided at the time of exit.