Incident investigation·March 28, 2023

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management to follow up on two self-incident reports and met with facility Administrator, Charito Santos. LPA is following up on self-incident report filed by the facility Administrator to CCL on 2/10/23. Per incident report, On 2/8/23 around 12:20pm resident (R1) screamed and was found by staff sprawled on the floor, informed us that they slipped while walking and hit their head on the wall. Staff called 911 immediately and transported R1 to the Hospital. R1 was discharged same day with a diagnosed with fracture in left shoulder after a fall. During today's visit, LPA reviewed R1's records including their care plan, Physician's Report (LIC602) and discharge documents dated 2/8/23 indicating that R1 sustained a fracture and follow up appointment next day with their Physician were it was determined that R1 does not need surgery and has another follow up appointment on 12/16/22. LPA also made observations to residents in care and conducted interviews with facility staff and residents that concluded R1 had an un-witnessed fall while walking in the hallway. Based on Physician's report (LIC602) dated 2/7/23 and R1's care plan dated 5/22/20 R1 is able to perform ADL's independently. The second self-incident report was received on 3/20/23 notifying CCL that on 3/15/23 around 5:30pm the facility received notification that R2 was going to be transferred to skilled nursing due to a wound that developed in their tail bone for sitting on their walker. During today's visit, LPA reviewed R2's Physician Report (LIC602) dated 12/28/22 that did not indicate any history of skin condition, R2 is ambulatory and able to perform ADL's independently. R2's care plan dated 5/1/20 confirmed that they use a walker to get around the facility. LPA discussed with Administrator that care plans are not current; Administrator agreed to update care plans and obtain R2's discharge documents to send them to LPA for review. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.