Follow-up·April 12, 2022

On 4/12/22 at 1:05pm, Licensing Program Analyst (LPA) C Lin arrived unannounced to conduct a case management visit as a result of receiving a self-report dated on 4/7/2022 to indicate a resident developed wound in stage 3 while in care. LPA met with the caregiver Gladys Salguero and explained the purpose of the visit. Administrator Ferdinand Gutierrez was unavailable and authorized the caregiver on the phone to sign on this report. At 1:10pm, LPA toured the facility and observed that the laundry room door was let opened with a long brown wood stick on purpose, laundry detergent was observed inside the laundry room. Staff stated that the dryer was missing a hose of exhausting heat when it was installed in February 2022, when the door was closed steam would be filled up the laundry room. Therefore, staff let the door open for about 2 hours every time when they did the laundry. 1 resident with Dementia and 1 resident with Cognitive issue were observed walking inside facility when the laundry room door was opened. Staff locked laundry room door during visit. At 1:30pm LPA reviewed the file of resident who developed pressure injury while in care. Staff stated that resident was sent to emergency room in time manner when wound was noticed, home health nurse was ordered by resident's physician when discharging from hospital. LPA spoke with home health nurse and hospice nurse from the agency Health Flex to be confirmed that resident's wound has been monitored and in care. However, facility was unable to provide document of resident's changing condition and update appraisal/care plan . LPA spoke with Administrator on the phone, Administrator admitted that resident's care plan has not been updated. The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with caregiver, LIC809D, Appeal Rights and a copy of this report provided.