Facility Evaluation Report

On 8/17/23, Licensing Program Analyst, (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit.

The Department conducted an investigation in relation to complaint control # 27-AS-20230227143013 . During the course of that investigation and based on facility records it was determined Resident 1 (R1) f ell on 11/19/2022, 11/29/2022, 12/16/2023, 12/24/2023, and 02/23/2023. Paramedics assessed R1 after the fall on 12/16/2023, but R1 was not taken to the hospital. Consumnes Fire Department Report #F202220234263 documents that facility staff S1 signed the Patient Care Report and acknowledged refusal of transport. S1 reported that the paramedics refused to transport Gregory to the hospital and that she was not the one to make the decision to not send R1 to the hospital however the Consumnes Fore Department Pre hospital Care Report states " staff signed against medical advice and witnessed via crew. No further patient care provided and crew cleared scene" R1 was not assessed at the hospital until after the fall on 02/23/2023 .

The resident's needs and service plan is dated 12/9/22 and was not updated after the fall from 12/16/23 or 12/24/23 despite the fact that fall prevention measures that the Administrator claims were in place were ineffective.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of Civil Penalties.

An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.