complaint·May 30, 2023

During the investigation process, it was indicated that a resident (Resident 1) was having difficulty with care to his infected feet. The resident’s feet appeared to have dry skin, were infected with what appeared to be yellow pus under several toenails and his feet were discolored. On 03/06/23 LPA Gurriere took photos of the resident’s feet which appeared to be in extremely poor condition. On 03/03/23 the facility staff contacted emergency services in an effort to have the resident seek medical treatment at the hospital. When the resident arrived at the hospital, it was reported that the resident refused care and was sent back to the facility without treatment. On 03/06/23, Donna Gurriere, Licensing Program Analyst met with the resident to discuss his medical treatment. LPA Gurriere asked the resident how he was doing with his feet and the resident stated that his feet were “Fine.” LPA Gurriere asked the resident if she could look at his feet and the resident allowed LPA Gurriere to see his feet. The resident refused care at the hospital, the resident could not get into see his doctor until May 2023 and the resident was not opened to home health treatment or hospice care. The resident was not getting any care at the facility to assist in his infected feet and toes. On 03/08/23, it was reported by the administrator that the resident was opened to the hospice agency to address the resident’s infected feet. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Unqualified staff are providing care to residents. During the interview process, the administrator, five staff persons, two residents, a nurse consultant and regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, staffing telephone numbers and staff training documents. During the investigation process, it was indicated that Resident 1 was having difficulty with care to his infected feet. The resident’s feet appeared to have dry skin, were infected with what appeared to be yellow pus under several toenails and his feet were discolored. On 03/06/23 LPA Gurriere took photos of the resident’s feet which appeared to be in extremely poor condition. The licensee shall be permitted to accept or retain a resident who has a healing wound under the supervision of an appropriately skilled professional. The licensee has since hired a nurse consultant to assist in care for the residents; however, at the time of the incident, a nurse was not involved in the resident’s care; home health services and hospice care were not offered to assist with the resident’s infected feet either. Staff were not qualified to know how to treat the resident’s feet, coupled with the fact that the resident was refusing treatment. On 03/08/23 the licensee was in contact with hospice services, and the hospice services opened up a contract with the resident. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Staff do not have enough supplies for residents . This allegation was substantiated and cited, refer to LIC 9099 dated 03/07/23. On 03/07/23 LPA Gurriere did a walk-through of the kitchen and noted that the facility had the appropriate food amount in perishables and nonperishable food. The facility had two types of juice available, cranberry, and strawberry, fresh vegetables, frozen items, dessert, sandwiches, cheese, and potatoes. The facility had several shelves of frozen food and nonperishable food. Food included soups, drinks, chicken, cranberries, bread, tater tots, rice, beans, and canned fruits. The menu was checked, and LPA Gurriere spoke with the cook. The cook is following the menu and the food was present for the cook to use. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . Staff are not meeting residents diapering needs . During the interview process, the administrator, five staff persons, one resident, a nurse consultant and regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, staffing telephone numbers and staff training documents. During the investigation process, it was indicated that a resident (Resident 2) was not being changed and diapered as needed. It was stated by some staff that the resident was not always toileted in a timely manner. However, overall, it was reported that the staff check on and change the resident at least every two hours. On 03/06/23 LPA Gurriere checked in on the resident and he had been recently changed and according to the care provider, she checked, and the resident was dry. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated .