Routine inspection·July 17, 2025

Citations

3 citations recorded^*CCLD

• 87463(f)Type A

  87463 Reappraisals: (f) The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation...This regulation is not met as evidenced by: Based on R1's charting notes reviewed, although the facility did reach out to R1's responsible party on 12/2/24 after the fall and later in the evening, the facility failed to communicate with R1's responsible party on 12/3/24 when R1 was constantly yelling for help and the facility documented a change in R1's condition which poses an immediate health and safety risk to residents in care.

• 87464(f)(1)Type A

  Care and supervision as defined by statute and rules

  87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interviews and records reviewed, R1 was a fall risk, required two-persons transfer, escort assistance and close supervision, however despite staff being aware, facility staff did not assist a Vitas Healthcare hospice aide on 12/2/24, leaving the hospice aide alone with R1. In addition, R1 fell on 12/2/24, and based on medical records, R1 had a rotation to his/her left leg and a deformity to his/her left hip, an acute, mildly displaced fracture of the left iliac wing extending to the acetabulum with associated widening of the left femoroacetabular joint space; an acute, comminuted, mildly displaced fracture of the left inferior pubic ramus, and a mild presacral edema without a definite sacral fracture. A hematoma involving the left iliacus and left pelvic sidewall was also present. This poses an immediate health and safety risk to residents in care.

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• 87465(a)(1)Type A

  Arrange appropriate medical and dental care

  87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not me as evidenced by: Based on documentation reviewed, R1 had a fall on 12/2/24 at 7am and was treated by the hospice nurse. However, it was noted that later in the evening of 12/2/24, R1 was constantly yelling for help. Based on staff interviews, on 12/3/2024, R1 was complaining of pain when changing R1’s diaper and reported it to the med-tech and constantly yelling for help. It was not until the following evening on 12/4/24 that R1 was sent out to the hospital after staff noted R1 complaining of left hip pain. Staff interviewed were unable to state why R1 was not sent out to the hospital earlier which poses an immediate health and safety risk to residents in care.

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