Facility Evaluation Report

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240306081830). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Rose Anguiano and explained the reason for the visit.

During the Department’s investigation, the following deficiencies were observed:

On 01/21/2024, at approximately 5:41 p.m., Resident #1 (R1) presented to the emergency department for abdominal pain. The records noted R1 had three days of abdominal pain and diarrhea. On 01/30/2024, the clinical update noted R1 tested positive for C. difficile colitis (C-diff). On 01/31/2024, R1 was discharged from the hospital to the facility with a new medication of Vancomycin to treat the C-diff infection. A review of the facility Medication Assistance Record (MARs) revealed no indication the new prescription for Vancomycin was administered as directed by the hospital.

The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that R1 tested positive for C. difficile colitis (C-diff). Additionally, the facility did not submit an exception request for a prohibited health condition, when R1 tested positive for C. difficile colitis (C-diff). R1’s Needs and Services Plan dated 12/26/2023 was not updated to reflect R1’s change in condition and develop a plan of care to meet R1’s needs.

Based on the numerous deficiencies noted during the course of the investigation of complaint 29-AS-20240306081830, the administrator did not demonstrate knowledge of the requirements of Title 22 Regulations, including care and supervision of residents.

Citations issued, exit interview conducted and , appeal rights given.