NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to investigate two complaints (#18-AS-20200803114859 & #18-AS-20210616082012). During LPA Colvin's investigation of the complaints, LPA Colvin observed some additional deficiencies. LPA Colvin met with Substitute Administrator Yusef Nofal and advised him of the purpose of the visit.
LPA Colvin had previously received Physician's Reports from the Licensee for the purpose of this investigation, which LPA Colvin reviewed. During the review of these medical documents, LPA Colvin observed that five (5) out of eleven (11) residents required some form of assistance or supervision with bathing (R1, R2, R3, R4, & R5). In LPA Colvin's initial interview with both staff and the Licensee/Administrator, it was relayed to LPA Colvin that the residents are able to bathe themselves independently and do not require the facility to provide any kind of monitoring, with the exception of R5. From LPA Colvin's review of the Physician's Reports provided by the Licensee/Administrator, LPA Colvin determined that this information is either inaccurate, or that the residents require a reappraisal of their needs and services that the facility needs to provide them.
During today's inspection, LPA Colvin reviewed the file for R2, the only resident of the four noted who still resides at the facility. LPA Colvib observed that in R2's Pre-Admission Appraisal that it was documented (page 2, under "Services Required") that R2 requires assistance from staff with showering. Since both the Licensee and direct care staff have stated to LPA Colvin that they do not provide R2 with assistance with bathing, they are not providing services required in accordance with the appraisal of R2's needs. Deficiency cited. Additionally, LPA Colvin observed that R2 has not had an updated Needs & Services Plan since admission to the facility back in 2019. Considering that there is debate or concern over R2's need for assistance in certain areas, it is especially troublesome that an updated Needs & Services Plan has not been created for R2 and evaluated with R2 and their responsible party (if any). Deficiency cited. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/06/2021
Section Cited
CCR
87464(d)
| 1
2
3
4
5
6
7 | Basic Services: (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...either directly or through outside resources. | 1
2
3
4
5
6
7 | Licensee agrees to have R2 (only resident of R1 - R4 still at facility) re-assessed both by the Licensee and by their Physician and obtain updated Physician's Report (done by physician) and Needs & Services Plan (done by Licensee). Licensee to provide a copy of both documents to LPA Colvin by the Plan of |
 | 8
9
10
11
12
13
14 | This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with 4 out of 11 residents (R1 - R4). Residents' Physician's Report state assistance is needed with bathing. Staff not providing assistance. This is a potential health risk to R1 - R4. | 8
9
10
11
12
13
14 | Correction date of 7/6/21. Additionally, if at least one of the documents maintain that R2 continues to need assistance with bathing, Licensee agrees to have staff provide this service/assitance to R2. |
Type B
07/06/2021
Section Cited
CCR87463(c)
| 1
2
3
4
5
6
7 | Reappraisals: (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement was not met by: | 1
2
3
4
5
6
7 | Licensee agrees to conduct a self-audit of all resident files and identify those who do not have a current (within the last 12 months) Needs & Services Plan. Licensee agrees to update any outdated Needs & Services Plans in accordance with this Regulation. Licensee may self-certify to LPA Colvin once complete. |
| 8
9
10
11
12
13
14 | Based on record review, the Licensee did not comply with the above regulation in at least 1 of 11 residents at the facility (R2). LPA Colvin observed that R2's last appraisal for Needs & Services was done back in 2018. This is a potential health risk to R2. | 8
9
10
11
12
13
14 | Self-certification to be submitted to LPA Colvin by no later than the Plan of Correction date of 7/6/21. |