Inspector’s narrative
What the inspector wrote
(Continued from LIC 9099) page 2 of 3
The Department interviews revealed multiple caregivers, LVNs, Med-Techs, and the Resident Services Director described monitoring practices, ADL assistance, and activity offerings for Resident #1 (R1) Executive Director David Armour explained caregivers do not chart each ADL task; refusals are documented by exception in digitized Progress Notes provided to the Department. The Department records review revealed service plans included ADL assistance, safety supervision, and activity programming; care notes documented monitoring and diet changes after physician orders; the posted monthly activity calendar was observed by LPA on multiple dates. The Department observations revealed R1 was groomed, room was clean, window intact, and activities were occurring per schedule during visits on 07/21/2021 and 10/27/2021.
Regarding the allegation, lack of supervision resulting in resident sustaining severe bruising. The Department interviews and records review revealed staff followed the facility’s fall response procedures when a large bruise was discovered on 07/06/2021: notifying clinical staff (Med-Tech/Resident Services Director), flagging the chart for increased monitoring, and conducting assessments. R1 denied an unwitnessed fall and exhibited full range of motion with no head trauma signs at the time of assessment. Staff increased observation after discovery. Based on evidence, staff acted according to policy.
Regarding the allegation, staff did not notify responsible party of change in condition. The Department records review revealed the responsible party became aware of the bruise during their 07/10/2021 visit and was informed in person at the facility. Pursuant to Title 22, Section 87211(a)(1)(B), a written report to the licensing agency and the responsible person is required within seven (7) days for serious injuries as determined by the attending physician. The bruise did not meet the definition of “serious bodily injury” under Title 22, and there is no regulatory requirement for immediate notification in this case.
(Continued on LIC9099-C)
(Continued from LIC9099-C) pages 3 of 3
Regarding the allegation, staff did not meet resident’s needs. The Department interviews revealed staff provided ADL assistance, with occasional refusals due to dementia-related behaviors (e.g., layering clothing, shaving refusals). ED reported the electric razor charger was replaced and shaving resumed consistently after care conferences. The Department records review revealed diet changes were implemented following physician orders post-hospitalization for Bell’s Palsy; Progress Notes reflected monitoring and adjustments. The Department observations on 10/27/2021 documented R1 cleanly shaven, well dressed, and room/restroom in good order.
Regarding the allegation, licensee did not provide resident a safe environment. The Department interviews and records review acknowledged historic concerns (e.g., cracked window and a picture frame with broken glass) that were reported and corrected. The Department observations on 07/21/2021 and 10/27/2021 revealed windows intact, no broken glass, clean non-sticky floors, and no observed hazards. Facility maintenance records and staff interviews confirmed responsive repairs.\
Regarding the allegation, licensee did not provide required resident activities. The Department interviews revealed scheduled activities in Compass Rose (memory care) including group walks, music, tactile stimulation (“busy boards”), games (e.g., dice activity), and pet therapy. The Department observations confirmed activities occurring per the posted calendar and availability of supplies (bingo, coloring, puzzles). While resident preference (walking) and engagement varied, evidence supports ongoing activity provision.
Based on interviews, observations, and records review, a preponderance of evidence does not exist to prove any of the six alleged violations occurred. Therefore, these allegations are UNSUBSTANTIATED.
An exit Interview was conducted with Executive Director Wes Hebner. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
The Department interviews revealed that on 07/06/2021, staff observed a large bruise on Resident #1(R1) involving the right thigh, lower leg, buttock, and hip area. Staff assessments documented full range of motion and no head trauma signs; however, staff did not notify the physician upon discovery and did not send the resident for evaluation. Staff #1 stated she was aware of the bruise but “got busy and forgot.” Staff #2 confirmed she did not notify the physician or family. The Department records review revealed the facility incident report was completed on 07/13/2021, seven days after the bruise was first observed.The responsible party transported R1 to a hospital on 07/10/2021 due to concern about possible fracture. Hospital documentation revealed diagnostic testing included an X-ray of the right hip and pelvis, which showed no acute fracture or dislocation, and a CT scan of the head, which showed no acute traumatic brain injury or subdural hematoma. Hospital staff noted the bruise appeared two to three days old and expressed concern that the facility had no
t notified family or reported any incident.
Based on interviews, records review, and hospital documentation, the preponderance of evidence supports that staff failed to seek timely medical care for R1 after a significant change in condition was observed. Therefore, this allegation is
SUBSTANTIATED
.
Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Hebner, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
