Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation for the complaint 26-AS-20240312154828, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Lead Staff Robert Foranda

On March 14, 2024, LPA Simi Rai interviewed ADM. ADM stated on August 1, 2023, R1 was admitted to the facility and there was no wound on the foot. ADM stated on September 14,2023 R1 went to urgent care because of the cellulitis on the bottom of foot was infected and there was an open wound.

ADM stated on February 19, 2024, R1 went to urgent care. ADM stated on February 20, 2024, R1 was discharged back to the facility. ADM stated the Doctor had told her that the wound was superficial. ADM stated on February 26, 2024, the home health nurse saw the wound was infected and decided to call 911.

ADM stated she did not do assessment every time R1 came back from the hospital or Sunnyvale Post Acute. ADM did not visit R1 before R1 came back to the facility. ADM stated she would see R1 when R1 came back to the facility. ADM stated she did not document anything in the facility.

Based on a review of R1’s needs and Services Plan (ANS), dated August 1, 2023, the ANS has no mention of R1’s catheter or pressure injury.

Based on records reviewed and interview conducted, the Administrator did not update R1’s Needs and Services plan. R1 had sustained a wound on 09/14/23. ADM stated she did not do assessment every time R1 came back from the hospital.