Facility Evaluation Report

Licensing Program Analyst (LPA) Huma Rahimi met with Staff #1 (S1) who granted access to the facility. The Administrator was contacted and LPA explained the reason for the visit. The purpose of the case management visit is to address deficiencies observed during the course of investigation control # 31-AS-20251027152920. Deficiencies observed were not alleged however are related to the complaint

During the course of the investigation control # 31-AS-20251027152920 the following were observed:

LPA was informed that the Administrator observed Resident #1 (R1) experiencing cognitive decline approximately two months ago. However, R1’s physician was not notified, and R1’s Appraisal/Needs and Services Plan was not updated to reflect the change in condition. Therefore, it was determined that the Administrator did not ensure that a timely reassessment and ongoing reappraisal were conducted, nor was the Needs and Services Plan revised in accordance with the resident’s change in condition.

Moreover, LPA was informed that R1 had a fall on 04/27/25 and a former resident #6 (R6) who no longer resides at the facility was throwing up and went unconscious on 05/17/2025. LPA was informed that for both incidents regarding R1 and R6, 9-1-1 was called and both residents were transferred to the hospital on the above mentioned dates. However, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R1 and R6. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. During today's visit, LPA collected both incident reports regarding R1 and R6.

Deficiencies issued and appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.