Follow-up·April 5, 2022

Licensing Program Analyst (LPA) Walters arrived unannounced and met with, Care Coordinator, Jennifer Ramos. The Administrator was not present for today’s visit. The purpose of this visit is to follow up on incident reports received in which multiple residents fell. LPA also is following up on an incident involving resident, R1. It was self-reported to Community Care Licensing that R1 complained that they weren’t feeling well. Staff S1 contacted that residents Power of Attorney and requested permission prior to contacting emergency. Facility Staff waited for Resident’s POA to arrive and take resident to the emergency room. During the visit, LPA gathered resident’s discharge paperwork, Physician Report, and Needs and Service Appraisal. At approximately 10:20 AM during tour with Care Coordinator, LPA observed that there was 1 activity staff (S2) providing supervision for 20 residents. Per record review, staff and Administrator 8 of those residents are a fall risk and require standby by assistance. LPA and Care Coordinator discussed having additional staff present to provide care and supervision for residents who are a fall risk. At approximately 10:30 AM LPA and JR observed resident R2 sitting outside on the patio with an assisted walking device. Per JR, R2 was not a fall risk and has no trouble ambulating throughout facility. LPA reviewed R1’s Physician Report and Needs and Service, Home Health Notes and Service Plan. Through record review which indicates that R2 requires standby assist and that they’re a fall risk. Per JR, they will contact their Physician to have his plan updated. LPA and Care Coordinator discussed monitoring residents for falls, and maintaining staffing in areas where residents who require assistance are congregating. LPA’s findings during this visit will require additional follow up with facility. There were no deficiencies cited during this visit.