complaint·December 20, 2024

Page 2 Allegation: Resident (R1) developed stage 4 pressure injury while in care. R1 was admitted to the facility on 1/08/22, and the Pre-placement Appraisal did not indicate that R1 had a pressure injury, however, the LIC602A Physician’s Report indicated that R1 had contractures to the upper and lower extremities, required continuous bed care, had fragile skin and needed to be repositioned every 2 to 3 hours. John Olivarez, licensee, stated that R1 has dementia, was bed bound and fully contractured when admitted to the facility and that R1 was always in fetal position. Licensee stated R1 was admitted to the facility as it was their hope that R1 could get to the point where R1 could sit up on her own. R1’s pressure injury was reported to him by staff which at the time he believes it was stage 1. The pressure injury worsened Staff (S3) stated she does not believe R1 should be admitted to the facility because S3 felt that R1 needed a higher level of care. R1 has dementia and needed assistance with all activities of daily living, with both feet and hands being contractured, and R1 was difficult to reposition. S3 also stated that the first person to notice the pressure injury was R1’s previous caregiver - when this private caregiver visited R1 and changed R1’s diaper and reported the pressure injury to her. S2 stated having noticed the wound which was approximately the size of a quarter. R1 had home health but S2 was not able to report anything because she never saw them, or she was busy assisting other residents. Between the time R1’s home health was terminated to the time R1 was hospitalized, S2 was cleaning R1’s wound. In September 2022, S2 noticed R1’s wound grown to about the size of a golf ball with soft center and had some pus. Two out of 3 residents interviewed did not know or remember R1 while the other 1 stated R1 can walk but R1’s documents and staff interviewed stated R1 is bedridden. Previous administrator (S1) stated R1’s daughter requested ambulance transportation on September 2022 to the hospital per advice nurse and R1’s doctor. Medical records showed R1 was admitted to the hospital on 9/16/22 and diagnosed with stage 4 sacral pressure injury and unstageable pressure injury at right lateral pelvis. .....continued on 9099C (page 3) Page 3 FM1 stated when R1 was admitted to the facility, R1’s pressure injury in the sacrum was superficial and eventually healed after home health services for 1 to 2 months. In May 2022, the pressure injury came back and R1 was placed on home health again and was discharged when the wound was not completely healed because the home health nurse felt it was okay to discharge R1 so long as the staff continue to change the dressing and reposition R1. FM1 and FM2 stated that they visited R1 several times a week for 30 minutes to 3 hours and staff did not check R1 unless they asked. FM1 stated she visited R1 on September 2022 on R1’s birthday and R1 was lethargic, unresponsive and barely able to eat. FM1 discussed the pressure injury with R1’s physician and requested for home health service. After 2 days, R1 was visited by a home health nurse and said that the injury was too advanced to treat with home health. FM1 called 9-1-1. Medical records showed R1 was admitted to the hospital on September 16, 2022 and was diagnosed with stage 4 pressure injury in the sacrum and unstageable pressure at right lateral pelvis. Based on interviews and records review, the allegation is substantiated. Allegation: Staff allowed resident to become severely dehydrated while in care. Staff (S2, S3 and S4) interviewed provided differing information in regard to R1 eating and drinking. S3 stated R1’s eating habits were inconsistent and that at the time of admission, R1 ate well and able to drink Ensure and water. S3 stated R1 ate a little, didn’t drink much, and noticed that R1 was dehydrated. S4 stated R1’s appetite and liquid intake were good, and that R1 was able to drink half a glass of water without issue. W1 and W2 stated that when they visited R1 and requested the staff to assist in transferring to wheelchair so that W1 can feed R1, the staff responded with an assumption that R1 will not eat. W1 stated that on their last visit prior to R1’s hospitalization, R1 appeared dehydrated. R1’s family members FM1 and FM2 stated that during heat wave, the facility has electric fans spread out in the facility blowing hot air around. R1 was sweaty, hot and lethargic. FM2 stated she brought misting fan that blows water to keep R1 cool; however, when FM2 visited R1 the fan was off and R1 was sweaty. The staff blamed each other for turning off the fan. R1 was sent out to the hospital and was diagnosed with hypernatremia and septic shock due to UTI among others. Based on information obtained, the allegation is substantiated. ........continued on 9099C (page 4) Page 4 Allegation: Staff did not seek timely medical attention for resident. Medical records showed R1 developed stage 4 pressure injury in the sacrum and unstageable pressure injury at right lateral pelvis and staff did not seek medical attention. It was R1’s family member who called 9-1-1. Allegation: Staff left resident soiled in urine for an unreasonable period of time. FM1, FM2, W1 and W2 stated they observed R1 soaked in urine. W1 stated that on 2 out of the 3 visits to R1, W1 observed R1 wet with urine and on one of these 2 visits, R1 was soaking wet up to the waist and W1 asked S3 for assistance when W1 changed R1. Based on interviews, the allegation is closed as substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. A $500.00 civil is assessed for deficiency section # 1569.269(a)(6) and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty were discussed with ADM and licensee. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.