Most inspections found no deficiencies, including the most recent annual inspection on November 14, 2024, which showed the facility in good condition with no issues. However, a complaint investigation in September 2024 substantiated neglect related to a delayed medical response after a resident’s fall in March 2024 that caused a fractured hip and extended pain. This was the most serious finding, involving failure to promptly call 911 after the injury. Earlier reports, including annual inspections in 2023 and the original licensing visit in 2022, showed compliance with only minor, isolated issues that were addressed. The facility’s record shows improvement since the serious incident, with the latest inspection free of deficiencies.
The inspection was a required annual unannounced visit conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in good condition with no deficiencies observed. The physical plant, kitchen, bedrooms, bathrooms, common areas, garage/laundry room, and surrounding grounds were all inspected and found compliant. Resident and staff files were complete with no immediate concerns, and emergency plans and drills were reviewed.
Report Facts
Hot water temperature: 110Hot water temperature: 112.1Facility capacity: 6Census: 5Fire extinguisher last serviced: Apr 1, 2024
The visit was a subsequent Case Management-Incident visit to issue final findings related to an incident where Resident #1 suffered a fall resulting in a fractured hip and hospitalization. The investigation was initiated following an incident report received on 03/15/2024 and prior visits and interviews.
Findings
The Department found sufficient evidence that the facility was responsible for neglect and lack of care and supervision by failing to obtain timely medical attention for Resident #1 after their fall on 03/08/2024, causing extended pain and injury. Facility staff delayed notifying the Administrator and calling 911 until the following morning.
Complaint Details
The visit was complaint-related, triggered by an incident report of a fall on 03/08/2024 resulting in a fractured hip. The complaint was substantiated based on evidence that the facility staff delayed medical care and notification.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to immediately telephone 9-1-1 after an injury resulting in an imminent threat to a resident’s health, causing extended pain from a hip fracture.
Type A
Report Facts
Capacity: 6Census: 6Deficiencies cited: 1Plan of Correction Due Date: Sep 16, 2024
Employees Mentioned
Name
Title
Context
Teresa Camara
Licensing Program Analyst
Conducted the subsequent Case Management-Incident visit and authored the report
Desaree Perera
Licensing Program Manager
Supervisor overseeing the licensing evaluation
Karthik Kanakaraj
Administrator
Facility administrator interviewed regarding the incident
Dennis Seng
Investigator
Assigned to the investigation by Community Care Licensing Investigations Branch
The visit was a Case Management - Incident investigation following a self-reported incident where resident #1 suffered a fall resulting in a fractured hip and hospitalization.
Findings
The facility reported that resident #1 fell in their private room on 03/08/2024, resulting in a fractured left hip and surgery. Staff and Administrator stated the resident was not considered a fall risk and had no prior falls since admission in 2018. Further investigation was referred to the Community Care Licensing Investigation's Branch.
Complaint Details
The visit was triggered by a self-reported incident involving resident #1's fall and injury. Further investigation was deemed necessary and the case was referred to the Investigation's Branch.
Report Facts
Facility capacity: 6Resident census: 5Incident date: Mar 8, 2024
Employees Mentioned
Name
Title
Context
Karthiga Vijayakumar
Administrator
Administrator involved in incident discussion and interview
The inspection was an unannounced required annual visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be in compliance with regulations during the visit. The physical plant was toured, including resident bedrooms, bathrooms, kitchen, common areas, and outdoor grounds, all of which were clean, properly furnished, and functional. Safety equipment such as fire extinguishers, smoke alarms, and carbon monoxide detectors were tested and functional. Resident and staff interviews revealed no immediate concerns.
Report Facts
Hot water temperature: 105.6Number of residents present: 6Facility capacity: 6Number of staff present: 2Number of resident bedrooms: 6Number of bathrooms: 3Number of staff bedrooms: 1
Employees Mentioned
Name
Title
Context
Karthiga Vijayakumar
Administrator
Facility Administrator present during inspection
Esther Cortez
Licensing Program Analyst
Conducted the inspection
Emma Cacho
Caregiver
Greeted Licensing Program Analyst at arrival
Inspection Report Original LicensingCensus: 6Capacity: 6Deficiencies: 2Nov 7, 2022
Visit Reason
A pre-licensing visit was conducted as part of a change of ownership application for Navita Residences Tull facility, including review of a dementia program and Hospice Waiver approval.
Findings
The facility was inspected for physical plant safety, resident accommodations, emergency preparedness, and cleanliness. Several items were found compliant, including fire clearance, adequate resident rooms, safety features, and proper storage of medications and supplies. Two items were noted for correction prior to licensure.
Deficiencies (2)
Description
Coordinate with Hospice and families for the relocation of resident to bedridden room.