Facility Evaluation Report

Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced and prior to visit LPAs conducted COVID-19 Precautionary pre screening, and wore a surgical mask while at facility. LPAs were screened at the front door by Caregiver.

While investigating complaint, 25-AS-20211118152214, several issues were found that were not allegations, but found to be violations of the regulations. The complaint regarded a resident who fell while at this facility. The resident fell in between staff checks. The resident was here after suffering falls at the previous living location and had back surgery prior to moving in. The resident had a history of falls and was a fall risk. There was no written plan of care addressing the resident's fall risk. The resident's room had a bed alarm, a mat to alert people the resident stood up, and did check on resident, but nothing in writing. Each facility is required to have a written plan of care for each resident to address their needs and how the facility is going to meet their needs.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Appeal rights left with facility representative.