Facility Evaluation Report

On 01/07/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on a self reported incident reports. LPA was greeted by Staff S1, stated the purpose of the visit, and was allowed entry into the facility.

On 10/17/24 @ 7:41AM, it was reported that R1 was wheezing and had shortness of breath. Staff S1 and Staff 2 notified Staff S3, who was stated to arrive to the facility shortly. S3 instructed S2 to take R1 to Urgent Care where R1 was diagnosed with Pleural effusion. S2 was advised by Urgent care to take R1 to Emergency Room (ER). R1 was seen @ Kaweah Medical Health Center ER where they did blood work and was discharged home with antibiotics @ 2PM. LPA requested discharge papers and documentation of R1's follow up appointments.

On 11/09/24 @ 0813AM Staff S4 reported to S3 that an incident occurred @ 0600AM when R1 was walking to their room with staff assistance, lost their balance and fell to their knees then over on their side. S4 did a body check and stated , other than redness, R1 seemed fine. @ 0813 AM, Staff S5 notified S3 that R1 was limping. S3 instructed S5 to take R1 to Urgent Care. It was reported R2 was OK, that they would be sore for a couple of days. On 11/12/24, records show R1 was taken back to urgent care for x-rays and was diagnosed with a bimalleoar ankle fracture and then referred to Kaweah Delta Healthcare Hospital ER. LPA obtained hospital discharge paper and requested additional documentation evidencing follow up care.

On 11/29/24 @ 9:30PM, Staff S4 stated while assisting Resident R2 out of the living room chair when R2 slid out of the chair and scooted on their bottom to the bathroom where staff assisted in changing R2. R2 then was assisted to their bedroom by S4 when R2 decided to scoot to their bed and scratched/bruised themselves on a bed rail. S4 informed S3. On 12/01/24, R2's bruise looked worse and was taken to Urgent care where they were diagnosed with a contusion on the left lower back. LPA asked for documentation evidencing medical treatment was sought.