complaint·April 3, 2025

LIC9099-C (Page 2) Allegation: Staff did not follow medical professional's prescribed orders Investigation Finding: Substantiated On 11/14/2024, the Department interviewed S1. S1 stated that R1 continually removed the medically ordered CPAP mask. The Department reviewed Medical Administration Records (MAR) from 01/2023 thru 03/2023 with prescribed medication orders (John Muir) from 10/27/2022 and observed not to be administered consistently. R1 was prescribed continuous positive airway pressure (CPAP) for obstructive sleep apnea in 2019. Doctor’s order prescribes to wear CPAP mask nightly and utilize distilled water. Records (ResMed) shows that no data was available during the months of Dec 2022-Jan 2023 which indicates CPAP machine was not in use. Further review of MAR and medication orders (10/27/22) there was no use of ketoconazole 2% shampoo for scalp, donepezil 23mg Tab was not administered according to February ’23 MAR and latanoprost .005% for glaucoma was not administered according to March ’23 MAR. Allegation: Staff isolated resident in care Investigation Finding: Substantiated On 10/11/20204 the Department interviewed W1. W1 stated that the staff isolated R1 to their room W1 stated that R1 developed a dementia related behavior of spitting inside. W1 stated that R1 was isolated and sat in her room alone all day, R1 ate her meals alone. On 10/03/2024 the Department interviewed S2 and S3. S2 stated that R1 wasn't isolated. R1 would stay in their room the first year because daughter brought DVD's and R1 would watch movies. LIC9099-C Continued... LIC9099-C (Page 3) S2 stated "we always gave R1 water. Sometimes R1 would refuse...daughter brought a lot of drinks. S2 stated, "we would give R1 cranberry juice, give R1 drink, like 8oz, sometimes R1 would have 3 glasses of 8oz. S2 stated that most of the time, R1 would be in TV room or their room. R1 would be in their room watching movie, iPad and R1's daughter would call her on her iPad. S3 stated that most of the time, R1 would be in TV room or their room. On 11/14/20204, the Department interviewed S1. S1 stated that R1 started spitting in 2022. There was a speech evaluation with John Muir Medical. When R1 would start spitting she would go back to her room. S1 stated, "...not fair for other residents when R1 spit food out and in front of other residents. R1 started spitting at clients/staff, spit over the walls, spitting food and saliva. S1 stated that R1 was kept in the room, then come out to eat meals, whereby R1 was placed at a table behind wall on the other side of wall. Based on the Departments observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations Staff did not follow medical professional's prescribed orders and Staff isolated resident in care are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided LIC9099-C (Page 7) Allegation: Resident sustained multiple ulcer wounds while in care Investigation Finding: Unsubstantiated It was alleged that R1 developed ulcer wounds in October 2020 at the right posterior foot and at the left foot. Review of documents indicate that on 10/8/2020 the facility was informed by W1 that R1 had developed blisters. Staff stated that no blisters had been observed. R1 was transferred to hospital for evaluation on 10/13/2020, however, the wounds were not staged. R1 was referred to a Foot and Podiatry specialist who indicated that the right posterior foot had a blister measuring 5 cm in diameter, and the left foot had a full thickness wound measuring 5 cm in diameter. The Specialist indicated that the wounds were Stage 2, not at prohibited stages of 3, 4, or Unstageable. On 10/15/2020, Home Health began for wound treatment at the home without issue. The Department obtained and reviewed the medical documents, which did not provide information to indicate when the wounds may have started to develop nor that they developed due to staff not performing a specific need. No information emerged that there was further concern for wounds until March of 2023. Per records review and Staff interviews, R1 was taken out for several hours by a private companion on what staff believed were extended car rides; on 2/14/2023 for approximately 4.5 hours; 2/21/2023 for approximately for approximately 4.5 hours; and on 2/24/2023 staff observed a 1.25 cm x 1.25 cm blister at the buttocks. Records indicate that W1 was informed, and that Staff continued to turn R1 every 2 hours and applied cream (started in 1/2022). On 2/24/2023 staff requested W1 to purchase an air mattress, which the facility purchased on 2/27/2023 after W1 refused. On 2/25/2023, records indicated that R1 was again taken on an outing 2/25/2023 for approximately 5.5 hours. On 2/26/25 staff observed that the blister had popped and another area was beginning to be irritated. LIC9099-C Continued... LIC9099-C (Page 8) R1 was medically evaluated on 2/28/2023. Home Health was started on 3/2/2/2023. On 3/8/2023 Home Health documented that the wounds had reduced, however, on 3/10/2023 Home Health arranged for R1 to be taken to wound care clinic for evaluation by W1, but no information was provided to the facility. On 3/13/2023 Home Health came to the home and noted R1’s wounds had reduced, however, on 3/15/2023 the facility was informed by the clinic that R1 should return as the injuries were now determined to be at Stage 3. W1 denied that R1 had been on outings that involved long periods of sitting in a car. No information emerged to corroborate what took place during those times. Allegation: Staff did not seek timely medical care for resident Investigation Finding: Unsubstantiated The Department found that in October of 2020 R1 had developed blisters at the right posterior foot and at the left foot. Review of documents indicate that on 10/8/2020 the facility was informed by W1 that R1 had developed blisters not observed by staff. R1 was transferred to hospital for evaluation on 10/13/2020, and to a Foot and Podiatry specialist who indicated that the right posterior foot had a blister measuring 5 cm in diameter, and the left foot had a full thickness wound measuring 5 cm in diameter. The Specialist indicated that the wounds were Stage 2, not at prohibited stages of 3, 4, or Unstageable. On 10/15/2020, Home Health began for wound treatment at the home without issue. Therefore, the Department is not able to determine that the facility did not seek immediately necessary medical care in a timely manner. LIC9099-C Continued... LIC9099-C (Page 9) The Department found that per records review and Staff interviews for 2023, R1 was taken out for several hours by a private companion on what staff believed were extended car rides; on 2/14/2023 for approximately 4.5 hours; 2/21/2023 for approximately for approximately 4.5 hours; and on 2/24/23 staff observed a 1.25 cm x 1.25 cm blister at the buttocks. Records indicate that W1 was informed, and that Staff continued to turn R1 every 2 hours and applied cream (started in 1/2022). On 2/25/2023, records indicated that R1 was again taken on an outing 2/25/2023 for approximately 5.5 hours. On 2/26/2023 staff observed that the blister had popped, and another area was beginning to be irritated. R1 was medically evaluated on 2/28/2023. Home Health was started on 3/2/2/2023. On 3/8/2023 Home Health documented that the wounds had reduced, however, on 3/10/2023 Home Health arranged for R1 to be taken to wound care clinic for evaluation by W1, but no information was provided to the facility. On 3/13/2023 Home Health came to the home and noted R1’s wounds had reduced, however, on 3/15/2023 the facility was informed by the clinic that R1 should return as the injuries were now determined to be at Stage 3. Therefore, the Department is not able to determine that the facility did not seek medical care in a timely manner. Allegation: Staff did not assist resident with proper hygiene needs Investigation Finding: Unsubstantiated On 10/11/2024 the Department interviewed W1. W1stated that R1 had an estimated five (5) Urinary Tract Infections (UTIs) in 2020 and that they have not found any documentation of the UTIs in their records nor proper administration of the ordered antibiotics. LIC9099-C Continued... LIC9099-C (Page 10) On 10/03/2024, the Department interviewed S2, S3 and S4. S2 stated that they would change R1's diaper in the mornings, lunch and dinner. S3 stated that they changed R1's diapers and that R1 needed 2 people to assist. S3 further stated that they checked R1's diaper 3-4 times a day. Checked R1 diaper after breakfast and change R1's diaper at night. S4 stated that R1 could not stand up good. But they would change R1's diaper at night every 2hrs. On 11/13/2024, the Department interviewed S1. S1 stated that Staff check all clients at night, and that Caregiver would take R1 to the bathroom every 2-3 hours. On 10/03/2023, the Department interviewed S1 who stated that staff would change R1s clothes every day and that they would change R1's diaper in the mornings, lunch and dinner. S2 stated that R1's diapers were changed and that R1 needed 2 people to assist. S2 stated that they checked R1's diaper 3-4 times a day, checked R1s diaper after breakfast and change R1's diaper at night. No information emerged to contradict the facility . Allegation: Staff did not ensure resident was hydrated Investigation Finding: Unsubstantiated On 10/03/2024, the Department interviewed S2, S3 and S4. S2 stated that they would give R1 water and juice 4x's a day with breakfast, lunch, dinner and in between. S3 stated "we always gave R1 water. Sometimes R1 would refuse...daughter brought a lot of drinks. S3 stated, "we would give R1 cranberry juice, give R1 drink, like 8oz, sometimes R1 would have 3 glasses of 8oz. LIC9099-C Continued... LIC9099-C (Page 11) Allegation: Staff did not ensure resident was nourished Investigation Finding: Unsubstantiated On 10/03/2024 S1 stated that last year (2023) R1 was not eating much. S1 stated, "We told the family that R1 would spit the food out and she was spitting food and saliva." S2 stated that R1's eating was 100%, it depended on R1. Sometimes R1 would spit and sometimes R1 would swallow, and we told the daughter. S2 stated that R1 ate vegetables, bread, protein, meat and fish. On 11/14/2024 and 12/23/2024 S2 stated that R1’s daughters would order snacks and have it delivered via e.g., soda, chips. R1 would eat chicken wings with BBQ sauce and eat anything sweet. ate well until March of 2023. The Department obtained medical records which did not indicate that R1 was malnourished. Allegation: Staff did not change resident's clothing Investigation Finding: Unsubstantiated On 10/03/2024, S2 stated that they would change R1’s clothes every day. S3 stated that R1's daughter would buy clothes online and send clothes for R1 to wear. W1 wanted R1 to feel comfortable. On 12/23/24 S1 stated that R1 wore house top/bottoms and wore pajamas. No information emerged to contradict the facility. LIC9099-C Continued... LIC9099-C (Page 12) Based on records review, interviews conducted, and observations made, the Department has investigated the above allegations of Resident sustained multiple ulcer wounds while in care, Staff did not seek timely medical care for resident, Staff did not assist resident with proper hygiene needs, Staff did not ensure resident was hydrated, Staff did not ensure resident was nourished and Staff did not change resident's clothing and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegations above are Unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.