Follow-up on corrections·April 19, 2023

On 4/19/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced visit to provide findings discovered during the course of a complaint investigation and met licensee. Prior to initiating the complaint visit, LPA completed the Department's COVID-19 precautions. LPA reviewed resident records, facility records and conducted interviews during the course of a complaint investigation. These additional findings were noted. On 10/14/22, LPA Cassie Yang collected records and conducted and interview. On 1/25/23, LPA Kevin Mknelly conducted a further review of records and interviews. On 2/7/23, LPA Mknelly interviewed R1 and spoke with Skilled Nursing staff. 4/18/23, LPA received Skilled nursing records. Licensee did not have a physician’s evaluation for R1 dated within 12 months of R1’s admission to the facility. Resident file reviews found that: Facility had only a Physician’s report dated 1/28/15. Statements from the licensee found that that 1/28/15 report was from R1’s prior placement and a new report was not obtained for within 12 months of R1’s admission to this facility. Furthermore, records review of skilled nursing records found resident had prior history chronic pain and upon admission to skilled nursing was prescribed several PRN medications and a sleep aid. Report continued Licensee did not have a current Appraisal/ needs and services plan though stated that R1 was declining to the point that R1 needed a higher level of care. Resident records review found a partial needs and services plan for R1 dated 4/20/21. Statements by the licensee were that they sought a higher level of care are R1’s change of condition made his care at this facility difficult. However, a new appraisal/ needs and services plan was not created to reflect the increased care needs of R1 As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Licensee . Copy of this report and appeal rights provided.