complaint·June 6, 2025

Emerald Valley staff first noticed redness on R1 bottom on 11/26/2023. Home health was requested on 11/28/2023 and a follow up was requested again on 12/7/2023, but services did not begin until 12/15/2023 after F1/Power of Attorney (POA) called R1’s doctor for a referral. Home health nurses visited R1 on 12/15/2023 and instructed staff to reposition R1 every two hours, and to change the dressing when it became soiled. Home health physical therapist found R1 sitting in R1 wheelchair, on R1 pressure injury, and reminded staff not to let R1 sit on R1 injury. R1 was admitted into the hospital on 12/20/2023 for low blood pressure, sacral pressure injury and blood in R1 urine. A hospital nurse (name unknown) staged R1 pressure injury as a stage 3, which was estimated to have been present for the past three weeks. R1 required debridement surgery and was discharged from the hospital back to Emerald Valley with hospice services. R1 was interviewed and said staff put R1 in R1 chair and R1 sat there all day. Staff always told R1, “We’ll get back to you,” when R1 requested help from them. R1, F1 and F2, frequently pressed R1 call button to request staff assistance but were rarely helped. Staff always said they were busy or made excuses. Emerald Valley caregivers were interviewed and admitted they found R1 lying in soiled diapers and soiled bedding on multiple occasions. NOC shift caregivers endorsed to AM and PM shifts to not put R1s water bottle on R1 bed as it often leaked and got R1 clothes and sheets wet. Because they could not transfer R1, they left R1 in wet clothes and bedding until the AM shift could change R1. Med techs were also interviewed and stated caregivers put off repositioning R1 because “R1 was too heavy.” Caregiver told me one of the other caregivers they need to constantly ask staff to reposition R1. Since staff rarely responded to their requests for help, F1 and F2 repositioned R1 themselves when they visited R1. Based on the information obtained, the findings are substantiated. Continues on LIC9099-C2 Allegation: Staff did not meet resident's diapering needs- Substantiated It was alleged staff did not meet resident’s diapering needs. On 1/16/2024, LPA reviewed caregivers’ care notes dated 11/28/2023 which noted while S7 was conducting a round check, S7 noticed R1’s water bottle behind R1’s bed fell over and water leaked on R1’s bed. S7 cannot transfer R1 and S7 left R1 in the wet bed. R1 was not changed until the following morning. R1 was in bed with wet sheets and clothes the entire night. On 1/23/2024, LPA interviewed W3 who stated that on 12/30/2023, W3 arrived at the facility to provide wound care to R1. W3 observed R1 lying in a soiled bed and diaper from 9 a.m. until 1:20 pm when facility staff arrived. Allegation: Staff did not ensure proper medication assistance was provided to resident in care- Substantiated Allegation: Staff did not attend to resident's call button- Substantiated It was alleged staff did not ensure proper medication assistance and staff did not attend to resident’s call button. On 12/30/2023 at 9:00 a.m., W5 was at R1’s bedside and R1 complained of pain. W5 pushed the call button to contact staff, but staff did not respond to R1’s call button until 1:20 p.m. According to W5, S8 who has the keys to the medical cart was on break. LPA attempted to interview S8 multiple times, but LPA was unable to obtain additional information. On 1/23/2024, LPA interviewed W3. W3 stated when W3 arrived at the facility to provide wound care to R1, W3 observed R1 lying in a soiled bed and diaper. W3 informed a facility staff that W5 has been trying to call a staff since 9:00 a.m. to assist R1 with medication. However, W3 stated no staff has responded and confirmed that staff did not respond until 1:20 p.m. On 1/16/2024, LPA reviewed R1’s medication administration record (MAR) and LPA did not observe pain medication was administered to R1 on 12/30/2024. Report Continues on LIC 9099 C3 Allegation: Staff did not ensure resident's wound care needs were met- Substantiated It was alleged that staff did not ensure the resident’s wound care needs were met. On 1/16/2024, LPA reviewed caregivers' notes dated 11/28/2023, which noted that while S7 was conducting a round check, S7 noticed R1’s water bottle behind R1’s bed had fallen over, and water leaked on R1’s bed. S7 cannot transfer R1 and S7 left R1 in the wet bed. R1 was not changed until the following morning. On 1/25/2024, LPA interviewed S7 via phone. S7 admitted that S7 left R1 knowing that R1's wound cannot be wet for a long period of time. On 11/28/2023, S2 noted R1 had redness on the peri-area and an open area on the top of R1 buttocks. On 12/20/2023, S8 noted that R1 bottom got infected, and S8 sent R1 to the hospital due to low blood pressure and an infected bed sore on R1 bottom. LPA attempted to contact S8 multiple times but was not able to get any new information. On 12/20/2023, R1 was sent out to the hospital for low blood pressure and an infected bed sore. R1 was admitted into hospice care on 12/22/2023. S3 instructed S1 and S13 that R1 will need to be transferred back to bed after breakfast and remain in R1's bed throughout the day and needed to be repositioned every two hours on each shift. S3 instructed S1 and S13 based on R1’s after-visit summary dated 12/22/2023 and hospice care plan. However, when asked, S3 was unsure if R1 was being rotated every two hours as instructed, due to a stage 3 pressure ulcer on R1's upper buttocks. Based on record reviews and interviews, the allegation above is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. - An immediate civil penalty of $500 is being assessed on today’s date. Civil penalty determination related to serious bodily injury is pending. LIC 421 IM is being issue today. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D. Exit interview conducted with Administrator, Marissa Espinoza a copy of this report and appeal right was provided. It was alleged that staff did not provide activities to residents in care; however, on 1/16/2024 at around 2:00 pm, while conducting a health and safety LPA observed the activities calendar on the countertop in the memory care unit and the AL unit. LPA observed residents who were in groups doing artwork and some were watching an animal show on television. LPA observed that residents are being encouraged by staff to join the activity. LPA observed R2 and R3 was sleeping in their room. LPA interview S2 on 1/16/2024. S2 stated that S2 would encourage residents to join the activity, but some refused, and we cannot force anyone. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.