Follow-up on corrections·August 21, 2024

On 8/21/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced case management visit to follow up on an exception request submitted for Resident 1 (R1). LPA met with Caregivers, Leila Tobias and Joanna Dizon who were informed of the purpose of the visit. Administrator, Kelly Welker was contacted over-the-phone and also informed of the purpose of LPA's visit. In the review of documents submitted for R1, it was discovered there was contradictory information related to the ambulatory status of R1. LPA reviewed R1's Physician's Report (LIC602A) dated 6/17/2024 which indicates R1 is non-ambulatory but also unable to independently transfer to and from bed, and noted they are bed bound. The LIC602A states R1 is not receiving hospice services, which was corroborated by facility staff. LPA was informed R1 is receiving home health services at the facility twice per week. LPA reviewed R1's home health records dated 6/12/2024 stating R1 requires consistent repositioning every two (2) hours. R1 was interviewed and reported they are unable to reposition themselves. Per a Fire Safety Inspection Request (STD. 850) dated 6/30/2022, the facility has a fire clearance for six (6) non-ambulatory elderly residents. Based on the aforementioned, the facility is in violation of their approved fire clearance. An exit interview was conducted and this report was reviewed with Administrator Welker over-the-phone and in-person with Caregivers Tobias and Dizon. A copy of this report was provided to the Caregiver Tobias along with a Confidential Names List (LIC 811), LIC809-D and LIC421M.