Facility Evaluation Report

On 12/19/2024 the Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an unannounced Case Management – Deficiency visit and met with ADMINISTRATOR MARY MONTIANO. The purpose of this visit is to issue citations on violations of Title 22 Regulations observed during an investigation for a complaint with complaint number 11-AS-2024725103218. During the investigation, records were reviewed, and interviews were conducted with facility clients and (current and former) staff. Reviews of St. Francis Hospital medical records revealed client R1 sustained a closed femoral neck fracture. The interview of R1 revealed he required assistance to get up after the fall. The interview of former staff S3 revealed on 07/21/2024 (the day of the incident) at approximately 10:30 PM, another client informed her that R1 had an unwitnessed fall. S3 stated she immediately responded to assess R1 who presented a change in condition as he was unable to ambulate. S3 stated R1 refused medical attention even though he immediately reported believing he had broken his hip and was in a lot of pain. S3 stated she called her supervisor S1 to report the incident and was instructed to request a non-emergency ambulance. The interview of caregiver supervisor S1 revealed that all staff had the authority to call 911 when they deemed necessary. S1 further stated S3 contacted her and informed her even though R1 refused medical attention,