Follow-up on corrections·April 15, 2021

On 4/15/2021, Licensing Program Analyst (LPA) A. Walton contacted Executive Director (ED), Shaun Rushforth to conduct a Case Management – Deficiencies visit via telephone due to COVID-19 and precautionary measures. LPA introduced self and discussed the purpose of the call with the ED. During the course of a complaint investigation, the following deficiency was observed. Residents at the above facility, were asked to push a button each morning that would notify staff that they are okay. If facility staff did not hear from a resident by a specific time each day, the facility would conduct a wellness check. On 5/15/2020 and 5/16/2020, facility staff conducted wellness checks for R1, after R1 did not push the button to notify staff. On 5/15/2020, S2 arrived at R1’s apartment to conduct a wellness check. S2 knocked on R1’s door and waited for R1 to respond. When R1 did not respond, S2 entered R1’s apartment. Per S2, R1 was in the bathroom and reported “being okay”, but, was “barely talking”. S2 informed S6 and requested that S6 conduct a follow up to check on R1. S6 was called away for an emergency that “trickled all day” and did not conduct the follow up. On 5/16/2020, S3 conducted a wellness check, as R1 did not push the button to check in with facility staff. S3 knocked on R1’s door, waited for a response, and entered R1’s apartment when R1 did not respond. Per S3, R1 was in the bathroom and reported “being okay”, but, was out of breath. S3 requested a follow up. S5 conducted a follow up, but, was sent to the wrong apartment and cleared the wrong resident. Continued to LIC809C At approximately 7:30 PM on 5/16/2020, R1’s family requested a wellness check for R1 and when R1’s family could not reach R1. S1 conducted the wellness check, and found R1 lying on the bathroom floor, unclothed and in urine. S1 assessed R1 and observed bruising to R1’s back and lower buttocks. Records revealed R1 was treated for a pressure ulcer, unspecified stage, deep tissue community acquired pressure injury, and dehydration. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809D. An immediate civil penalty is being assessed in the amount of $500 in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Executive Director. Appeal Rights and a copy of this report was discussed and provided via email and an electronic read receipt confirms receiving these documents. Facility representative signature on file.