Post-licensing visit·December 1, 2021

Licensing Program Analyst (LPA) Albert Johnson arrived to conduct an unannounced Post Licensing inspection /case management visit for multiple falls for R1 and a medication error for R2. LPA reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures in the file of S1 during the Post-Licensing Inspection. LPA reviewed R1 and R2's files, during the file review LPA observed that R1 was sent out for a fall on 11/20/2021 and was subsequently diagnosed with kidney failure/kidney injury and has not returned to the facility. R1 does not have a TB test on file. R2 was admitted to hospice on 5/20/2021. LPA observed the following posted at the entrance of the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. Exit interview held with Administrator and a copy of report given along with appeal rights at the conclusion of the visit.