Follow-up on corrections·December 13, 2021

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Kortnie Spitznogle who is authorized to review and sign reports. During review of resident #1's facility file, LPA did not notice a Service Plan in the folder. LPA spoke with Resident Care Director (RCD) regarding missing Service Plan. RCD stated they completed an assessment for R1 and was signed by family. RCD proceeded to print a copy of the Needs and Service Plan dated and signed by family on 04/28/2021. Upon further review of resident file, LPA observed a Physician Communication sheets, dated 11/22/2021, stating "Resident was sent out to the hospital 11/22/21 @ 3:00 p.m. due to change in condition." Another Physician Communication sheet, dated 11/19/2021, stated " Resident was found on the floor for the 3rd time this week on the floor. Resident had an unwitnessed fall." Another Physician Communication sheet, dated 11/19/2021, stated " Resident returned from hospital 11/17/21 @ 10:30 a.m. w/ fractured ankle." LPA also observed Narrative Charting notes that mentioned R1's multiple falls, fractured ankle, and change in condition. LPA questioned RCD if a new Needs and Service Plan was created due to the change in condition R1 had been presenting. RCD stated " no we have not. But, we will do that right away." LPA educated staff on when a reappraisal is needed. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Copy of the report and appeal rights given to admin via email.