Facility Evaluation Report
On 05/03/2023 in conjunction with a subsequent complaint visit control number 31-AS-20230427111039, Licensing Program Analyst (LPA) Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. LPA met with Administrator Designee Ricky Desahagun, LPA spoke with Administrator David Taylor over the phone informed them of the purpose of the visit.
On 05/02/2023 during interviews with staff and residents it was revealed resident #3 (R3) had a fall some time in the week of 04/09/2023. Interview with Ricky on 05/03/2023 revealed a nurse from Home Heath had seen R3 who took her vitals and reported no issues. A physical therapist had also visited the resident but informed facility R3 could not continue because resident was complaining of pain when moved. According to Ricky, physical therapy was placed on hold until R3 is examined to determine they are fine to continue with physical therapy. LPA advised Ricky resident needs to receive medical attention to rule out serious injury from fall. Ricky called the Administrator David who informed Ricky, R3 is in hospice. Ricky could not provide to LPA name of hospice or date of admission to hospice for R3. On 05/03/2023 LPA made a follow-up visit to confirm if resident had received medical attention. Administrator David informed LPA R3 was seen by Home Health and is being placed on hospice. Administrator David could not provide name of Hospice or date of admission to hospice. LPA again advised Ricky and David to call 911. Ricky called 911 at 10:55 a.m. and ambulance arrived at 11:38 a.m. to transport R3 to the hospital.
On 05/02/2023 LPA observed Ricky count medication and LPA compared the count with Centrality Stored Medication Logs and Medication Administration Records (MAR). LPA observed pill counts were over the total quantity number of pills listed on the prescribed medication bottles for resident #2(R2) and resident #6(R6). LPA spoke with the Administrator David over the phone and Administrator explained, “They shouldn’t do that, I’ve trained them.” In reference to staff pouring pills from one bottle to another.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction