complaint·February 4, 2021

(continued from LIC 9099) The complainants concern is that Resident #1 (R1) sustained pressure injuries while in care. IB Investigator Dennis Seng conducted interviews with facility staff on 03/04/2020. Staff interviewed were the primary care staff prior to R1’s hospitalization. The interview revealed that Staff #1 (S1) questioned R1 and physically conducted body checks only when R1 felt pain anywhere on the body. Staff #2 (S2) indicated that regular body checks were conducted on R1, however, when asked, could not recall how the body checks were performed. Medical Records were subpoenaed on 02/24/2020 and received by the department on 03/11/2020. LPA reviewed hospital records on 01/30/2021. Medical records revealed that the R1 was noted to have pressure sore wound on admission (02/11/20) by the nurse. Wound Care Specialist nurse evaluated the pressure injury (pressure sore) of R1 on 02/12/2020 and stated that R1 had Pressure Injury upon admission on 02/11/2020 and staged the right shoulder (Pressure Sore Injury stage II) and sacrum (Pressure Sore Injury stage III). Based on information gathered during the course of the investigation, the allegation is deemed substantiated. Deficiency and civil penalty assessed for a violation that resulted in an injury or illness to a resident in care. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(e) Appeal rights discussed and given. Exit interview conducted and report issued. (continued from LIC 9099-A) Regarding the allegation that the facilities has scabies, LPA record review revealed that the facility had scabies outbreak but this was reported to Los Angeles County Department of Health (LACDPH) who provided guidance to the facility to address the outbreak and eventually was cleared by the LACDPH on July 2019. While the facility continued to have small outbreaks, LPA interview with former administrator revealed that the former administrator trained staff to care for those residents with scabies per the Center for Disease Control (CDC) guidelines and put the protocol in place in accordance with LACDPH and CDC guideline. Regarding the allegation that the facility has insufficient staffing to meet the residents’ needs, IB Investigator Seng’s interview with care staff revealed that R1 would like to shower on R1’s own and would get upset if care staff assist R1 during shower but would remain on stand by while R1 is taking shower. Moreover, all three (3) care staff interviewed also revealed that R1 could change own diaper and the staff offered to assist but was refused by R1. LPA record review revealed that the facility has four (4) care staff during morning shift (6:00 AM to 3:30 PM) with two (2) staff on rotational duty that could assist with care if needed and three (3) care staff during afternoon shift (2:30 PM to 11:00 PM) with one (1) to two (2) additional staff on rotational duty that could assist with care if needed. Based on the information gathered during the course of the investigation, the allegations above are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.