Follow-up on corrections·January 11, 2024

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite deficiencies resulting from an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Services Coordinator Carol Braun. LPA also met with Executive Director Tim Jeffers. On 09/05/2023, the CCLD San Diego Regional Office received an LIC624 Incident Report from the licensee. Per the LIC624: On 08/31/2023 around 4:00 PM, Resident #1 (R1) fell at the facility, requiring them to be sent to a hospital emergency room for medical care. [See LIC 811 Confidential Names List for a description of person identifiers used]. CCLD’s investigation involved a brief facility tour on 09/18/2023, followed by welfare check on R1 via a collateral visit. CCLD also interviewed relevant residents, staff, and outside sources, and reviewed pertinent care records and correspondence. According to R1’s LIC602 Physician’s Report and corroborated by the appraisals/assessments which Licensee performed on R1: for most of R1’s residency at the facility (which began in 2017), R1 was historically independent with Activities of Daily Living (ADLs), to include walking and transferring, and required no assistive device such as a cane, walker, or wheelchair. Records and interviews of residents and staff, aligned to show: On 08/29/2023, R1’s spouse and roommate, Resident #2 (R2) approached facility management to tell them that R1 was falling frequently inside their bedroom, and that this new trend had occurred over the last “couple of weeks.” R2 admitted that they initially did not report R1’s falls to staff, but now recognized staff help was needed to maintain R1’s safety. Then on 08/31/2023, R1 fell at the facility, sustaining a nosebleed, skin lacerations on forehead and knee, and bruising to face, buttock, and leg. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Medical records showed R1 was diagnosed with a fracture of “C5 endplate” (i.e., a bone in their neck), for which R1 had to wear a collar device. R1 told CCLD they also experienced changes in their visual perception / processing, which lasted for a few weeks after the fall. Records, interviews, and E-mails further showed: From the time Licensee received constructive knowledge of R1’s new fall-risk on 08/29/2023, until the time R1 fell and was hospitalized on 08/31/2023, Licensee verbally told R2 that R1 needed to relocate to another care facility since R1’s now required caregiving assistance. However, Licensee’s staff did not meet with R1 in person to perform a written reappraisal of their care needs, nor notify R1’s physician of what R2 reported to them about R1. Licensee also did not assign any caregiver to R1 to help mitigate fall risk, either from its own staff pool or from a contracted outside source (such as a home care agency). On 09/01/2023, hospital staff determined R1 was ready to be discharged back to the facility, but facility management told hospital staff that R1 could not return to the facility to due needing a higher level of care. R1 instead went to a skilled nursing facility (SNF). On 09/02/2023, facility management referred R2 to a third-party placement/referral agent, who subsequently helped R1 move from the SNF to another permanent residence. Licensee did not issue R1 a 30-day written notice to move-out from the facility, as was required. E-mail and interviews showed R1’s move-out occurred under duress: R2 appealed to the SNF to extend R1’s stay to allow the more time to research and find another residence for them, but that appeal was denied. Unable to return to St. Paul’s Manor, R1 was discharged to their new residence on 09/12/2023. Based on records and interviews, a preponderance of evidence exists to show: a) Upon receiving constructive knowledge of a change in condition, Licensee did not observe/reappraise R1, report changes to R1’s physician, and provide appropriate assistance for R1’s unmet need, as were required; and, b) Licensee evicted R1 from the facility without giving them the required 30-day written notice. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). One of the violations was material to R1 sustaining serious bodily injury; an immediate civil penalty of $500 was also assessed (refer to the LIC421-IM). Plans of Correction was jointly developed with the licensee. An exit interview was conducted with Braun and Jeffers, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.