Facility Evaluation Report

Licensing Program Analyst (LPA) Samer Haddadin conducted an announced case management visit to the facility. LPA Haddadin was greeted and granted entry by Administrator (AD) Weiner Elena . The purpose of the visit was to address deficiencies identified during the investigation of complaint #22-AS-20250417112836. The following deficiencies were observed:

Per hospice records, between October 2023 and April 2025, R1 sustained at least nine documented falls. The earliest occurred on October 29, 2023, when R1 fell while attempting to transfer from bed to wheelchair. On November 2, 2023, Hospice record also showed that R1 had a skin tear to the left elbow. Facility had no records documenting regarding the falls or the skin tear . R1 sustained a second fall on November 8, 2023, and complained of left hip pain. R1 was transferred to Kaiser Hospital and diagnosed with left intertrochanteric femur fracture and underwent surgical repair the following day. R1 was later transferred to Post Acute Care for Rehabilitation. The facility’s internal self-report reflects the fall entry was not documented until November 29, 2023. Despite the seriousness of the incident, no significant changes were made to R1’s supervision schedule or care plan. On December 17, 2024, R1 complained of knee pain and swelling which was reported by the facility Med Tech to Vitas Hospice nurse. The visiting nurse prescribed Tylenol for R1’s pain and instructions to staff to monitor the swelling and contract hospice if needed. {***CONTINUE***809C}