Follow-up on corrections·November 4, 2024

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Helen Enriquez and explained the purpose of the visit. LPA Moleski closed a complaint investigation at this facility today. During the course of this investigation, LPA Moleski discovered deficiencies unrelated to the allegation made in the complaint report. LPA Moleski was previously informed by Enriquez that R1 had suffered a fracture to their right upper arm around the date of Friday, July 19, 2024. Enriquez had no documentation available regarding this injury, such as an incident report or other medical documentation, and no additional documentation regarding this resident. These deficiencies were previously addressed during a case management visit on 8/12/24. Enriquez said that R1 was sent to the emergency room on July 19, 2024 and returned on that same date with a sling provided by the hospital. Enriquez said that a physician had requested an outpatient orthopedic consultation visit for R1 to be held on the following Monday, July 22, 2024. Enriquez said that she was not able to take R1 to the hospital for this visit because she would be out of the area on that date. Enriquez said she asked the doctor to reschedule, but was told that R1 needed to be seen immediately. Enriquez said she told R1’s case manager she would be able to take R1 to the hospital, but not immediately. Enriquez said that R1’s case manager felt R1’s needs were not being met, to which Enriquez said R1 could be moved out. R1 was moved out by their case worker shortly afterward, on or around July 26, according to Enriquez. Enriquez said that one of her staff members has their driver’s license, but she would have to pay for a relief caregiver while they were transporting R1. Enriquez said that she was not compensated for transportation to R1’s medical appointments. [continued 9099-C] 22 CCR Section 87465(a)(2) states that licensees “shall provide assistance in meeting necessary medical … needs … [which] includes transportation” to medical facilities able to meet residents’ needs. It further states that, “in providing transportation the licensee shall do so directly or make arrangements for this service.” 22 CCR Section 87464 describes basic services which are required in order to obtain and maintain a license. Section 87464(f)(6) states that basic services shall at a minimum include “arrangements to meet health needs, including arranging transportation, as specified in Section 87465.” In an interview, R1’s case manager, who is also a nurse, said that R1 was never taken to the orthopedic visit while at Trinity Care Home, and did not receive the needed medical consultation until after being placed elsewhere. R1’s case manager said the visit was medically necessary, and R1 should have been seen immediately. In an interview, R1’s home health nurse said that R1 should have received this orthopedic consultation immediately. On July 22, 2024, R1’s home health nurse visited the facility to check on R1’s condition. In an interview, R1’s home health nurse said that they found R1 with their sling off, and with a shirt pulled over their head. The home health nurse said that staff present did not know where the sling was. Then, two days later, on July 24, 2024, the nurse arrived for another visit and found R1 was again without the sling provided by the hospital, but instead was wearing a wrist brace. In an interview, a staff member who was present during the home health visit on July 22, 2024 (S1) said that R1’s sling “went missing.” S1 said that another staff member had misplaced it, but said they later found it. Another staff member present on this date (S2) confirmed that R1 was not wearing their sling. S5 said R1’s sling was washed and later left in R1’s closet. S5 did not know why the sling had not been put back on R1 afterward. This facility is hereby cited per 22 CCR Sections 87465(a)(2) and 87464(f)(4). An exit interview was held with Enriquez. Appeal rights and a copy of this report was left with Enriquez.