Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - deficiencies visit based on violations observed during 2 complaint investigations for complaint control number 26-AS-20221215152806 and 26-AS-20230714114133. LPA met with General Manger, Billy Mitchell and Resident Care Director, Jocelyne Bailon Solache .

During the investigation for complaint control number 26-AS-20221215152806, it was found that on 07/09/2021, R1’s service plan was updated due to a change of condition in which R1 was moved from assisted living to memory care. On 04/07/2022, R1’s level of care increased from level 1 to level 2, which stated R1 was a low potential for falls to moderate potential for falls. On 04/29/2022, R1 went from a moderate potential for falls to a high potential for falls. On 11/23/2022, R1’s level of care increased from a level 2 to a level 10. Based on record review, resident (R1) did not obtain an updated physician’s report after any changes of conditions based on the re-evaluations and updated service plans. R1's physician's report was dated on 02/11/2021. R1 was admitted to the facility on 02/28/2021.

R1’s service plans dated 07/08/2021, 04/07/2022, 04/29/2022, 09/09/2022, and 11/12/2022 were not signed by R1 and R1’s responsible party. The facility was unable to produce documents or proof to show the service plans were reviewed with R1’s and R1’s responsible party.

On 04/30/2022, 06/24/2022, 07/05/2022, 07/06/2022, 08/09/2022, 09/23/2022, 10/07/2022 R1 sustained falls. Based on record review, it was not noted or indicated that R1’s physician was notified of the falls. SEE LIC809-C.