Inspection visit

complaintJanuary 12, 2023

BLUEMEADOW CARELicense 0792008252 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

The Department investigated resident developed a pressure injury requiring hospitalization. Based on record review, R1 was admitted to the facility on June of 2015 under the prior License. Sometime in April 2020, R1’s right heel bumped on the wheelchair. On 4/8/2020, R1’s wound was diagnosed unstageable by attending physician at John Muir Hospital and wound care was initiated. The same day, home health nurse instructed facility staff to supervise R1 at all times, to off-load pressure to right heel at all times, feed R1 with high protein diet and to reposition every two hours. On 5/18/2020 and 6/5/2020, Home Health Nurse observed R1’s wound pressed against the bed despite instructions to off-load and elevate the heel with pillows. On 6/9/2020, R1 was admitted to Emergency Department and the pressure injury was diagnosed at Stage 4. Bone was exposed and 60% of the heel was necrotic tissue. Test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream. The Department investigated resident had an unexplained injury. On 5/28/2020, facility staff informed home health nurse that R1 had fallen from the wheelchair earlier in the day and sustained a skin tear to the chin when R1 leaned over in the wheelchair to pick up something. On 6/9/2020, caregiver advised R1’s left eye had been bleeding for the past two days but could not explain why or how R1 sustained the injury. Upon R1’s admission to the Emergency Department on 6/9/2020, R1 was diagnosed with bilateral conjunctivitis. Based on the Department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8) and Health and Safety Code are being cited on the attached LIC 9099D. A $500 Civil Penalty is being assessed. Civil penalty determination related to serious bodily injury is pending. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator. The Department investigated residents needs are not being met due to insufficient staffing. Based on interview with 3 staff and 3 residents, 3 of 3 staff and 3 of 3 residents stated that there are no issues with staffing. The Department investigated resident not afforded dignity while in care. Based on interview with 3 residents, 2 of 3 residents stated they are provided with privacy. During an interview with 3 staff, 3 of 3 staff stated they close the door when they are changing the residents and assisting residents in the bathroom. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED . Exit interview conducted with Administrator and a copy of this report provided. Based on documents reviewed, facility contacted home health nurses regarding R1’s health status. This agency has investigated the complaint alleging staff did not notify resident’s authorized representative of resident’s change in condition. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. There is no deficiency noted. Exit interview was conducted with Administrator and a copy of this report was provided.

Citations

5 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87411(a)(1)(D)Type B
87411(a)(1)(D) REPORT REQUIREMENTS(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any residents. This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. Facility did not submit incident reports for when R1 fell off the wheelchair and sustained a cut on the chin in April 2020. In addition on May 28, 2020 where R1 was observed with bleeding eyes which poses a potential health and safety risk to persons in care.
Read full inspector narrative
1569.269(a)(10)Type A
1569.269(a)(10) ENUMERATED RIGHTS; SEVERABILITY(a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect...This requirement is not met as evidenced by: Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. In April 2020, Home Health nurse instructed staff to off-load pressure to R1’s right heel at all times and to reposition every 2 hours. Nurse observed R1’s wound pressed against the bed twice. On 6/9/2020, R1 was admitted to hospital and pressure injury was diagnosed at Stage 4. Bone was exposed and test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream.
87466Type A
87466 OBSERVATION OF THE RESIDENTThe licensee shall ensure that residents are regularly observed for changes in physical......changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. Facility staff were instructed by Home Health nurse to supervise R1 at all times. On 5/28/2020, R1 fell off the wheelchair which resulted to R1 sustaining a cut on the chin. On 6/9/2020, staff informed Home Health nurse that R1’s eyes have been bleeding for two days. R1’s primary doctor was not notified.
87705(c)(5)Type B
87705(c)(5) CARE OF PERSONS WITH DEMENTIA(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an .... and a reappraisal done at least annually... This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. LPAs observed R4 does not have an updated appraisal on file which poses a potential health and safety risk to persons in care.
87705(f)(2)Type A
87705(f)(2) CARE OF PERSONS WITH DEMENTIA(f)The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with regulation cited above. LPAs observed unlocked cleaning supplies in unlocked laundry room which poses an immediate health and safety risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 12, 2023 inspection of BLUEMEADOW CARE?

This was a complaint inspection of BLUEMEADOW CARE on January 12, 2023. 2 citations were issued: 2 Type A (serious).

Were any citations issued to BLUEMEADOW CARE on January 12, 2023?

Yes, 2 citations were issued (2 Type A, 0 Type B). The first citation was for: "87411(a)(1)(D) REPORT REQUIREMENTS(a) Each licensee shall furnish to the licensing agency such reports as the Department..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·January 12, 2023