Facility Evaluation Report

On 03/14/24, Licensing Program Analysts (LPA) L. Salazar and S. Doucette arrived at the facility unannounced to conduct a 10 day visit. LPAs were greeted by caregiver and were allowed entry into the facility. Administrator arrived to the facility shortly after.

LPAs toured the facility and observed 5 residents in care. 1 out of the 5 residents was observed in a hospital bed with full bed rails. A physician's order to admit R1 on Hospice care was observed, however, no Dr's signature is observed on the order and no Hospice care plan was in file. R1 was observed to have 2 unstageable pressure injuries on each heel.

Resident R2 was observed in a hospital bed with half bed rails. Administrator stated R2 was on Hospice, however, no hospice care plan was observed on file. LPA observed a paper from Traditions Health admitting R2 to Hospice, however, there is no doctor signature on the order. LPAs observed residents in care to have dementia. LPAs observed 2 hours of dementia training in file for Staff S1.

Based on today’s visit, deficiencies are being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D.

An exit interview was conducted with Administrator. A copy of this report and appeal rights were discussed and provided at the time of visit. A plan of correction was developed and reviewed by Administrator with a POC date of 03/15/24.