Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an case management visit to address information obtained during the complaint investigation 8/10/2023. LPA Rai met with LVN Residential Manager, Fidel Manuel and stated the purpose of the visit.

During investigation, it was disclosed that the resident (R1) did not have a physician's order to use bed rails. Resident Service Director (RSD) stated he/she was not aware of the regulation and did not have a physician's order on R1's file for using bed rails. RSD confirmed R1 was not receiving hospice services at the time of using the bed rails.

During review of documents obtained during investigation, R1's has a history of falls, but Need and Services Plan did not state how facility will meet R1's fall-risk behavior. Based on review of R1's Appraisal dated 5/10/2023 stated R1 had a 9 episodes of fall in the past year. Based on review of R1's Physician's Report dated 6/17/2022, R1's physician has noted under "Other Conditions" as repeated falls. R1's Service Plan dated 5/10/2023 did mention the history of falls but it did not address R1's needs and how the facility would address this 'Physical/Health" concern.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with LVN Residential Manager, Fidel Manuel. A copy of the report and Appeal Rights were provided.