Facility Evaluation Report

Licensing Program Analyst (LPA) Toan Luong conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20210830163115). LPA Luong met with

Business Administrator Denay Ramirez. The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20210830163115, Investigator Santana observed the following deficiencies:

R1’s Service Plan dated 07/24/2021, was not updated until 09/01/2021, even though a reassessment should have been completed after the fall incidents, the last fall being on 08/16/2021.

R1 had a fall on 08/07/2021 and 08/16/2021 sustaining injuries which required hospitalization. There is no record the Regional Office received any Unusual Incident Reports (UIRs) for the 08/07/2021 and 08/16/2021 incidents. The Director stated she must have mistakenly “shredded” the coversheets for the 8/7/2021 and 8/16/2021 UIRs and could provide no proof of submission .

In addition, the Facility Resident Services Director maintained that she faxed the 08/07/2021 incident report to the Regional Office on 08/11/2021, even though the Director was not working at the facility on 8/10/2021 or 8/11/2021, and a substitute nurse filled in for the Director on those dates.

LPA issued citation, conducted exit interview, and emailed appeal rights and report to Business Administrator.