complaint·February 7, 2023

CW added that they felt that the facility abandoned R1 because of the wound and was unlawful to not accept the resident back. Later that same day, starting at 10:29 a.m., interview with R1 revealed that they moved into the facility on 01/27/2023. Upon admission, R1 added that the facility was aware of the wound on their leg and proceeded with admission. R1 stated that during the signing of intake documents, the Administrator and staff were demanding that R1 to go to the hospital for an evaluation of the leg. R1 added that they have been receiving home health wound services for six (6) months. R1 stated that on 02/03/2023, the paramedics came to take to them to the hospital. R1 stated they felt afraid, lied to and abandoned as the facility sent them out to the hospital and didn't not want to accept them back because of the pressure injury to their leg. That same day, interview with outside agency, starting at 12:41 p.m. confirmed what R1 and CW stated. Outside agency added that on 02/05/2023, the hospital spoke to a staff member who stated that R1 could not return to the facility. Additionally, on 02/06/2023, outside agency was able to speak with Administrator Pink regarding the return on R1 to the facility. R1 returned to the facility on 02/06/2023. That same day, interview with Administrator Tillman Pink, starting at 1:15 p.m revealed that the facility was out of compliance because of a stage 3 pressure injury to R1's leg that needed medical attention. A review of medical documents obtained for R1, which started at 11:45 a.m., revealed that the discharge documentation from the hospital stated that the resident presented with a diabetic food injury; however, there was no indication that R1 developed a Stage 3 pressure injury. The facility wanted R1 to go to hospital or a skilled nursing facility (SNF) to have the injury heal and then allow the resident to return to the facility. Administrator Pink confirmed that R1 returned to the facility on 02/06/2023 . Although the R1 presented with a diabetic ulcer on their left leg, the facility did their due diligence in sending the resident out for evaluation. But, based on interviews, the facility did not want to accept the resident back, thus, abandoning R1 at the hospital for two (2) days until an outside agency was able to intervene, at which time R1 was allowed to return on 02/06/2023. Based on evidence gathered during the investigation, the allegation facility abandoned resident is deemed substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Regarding the allegation facility failed to return resident’s personal belongings. Interview with R1 on 02/07/2023 starting at 10:29 a.m. revealed that R1 was worried about their personal belongings when admitted to the hospital. Further interview with R1 stated that the facility locked the door to their room. Later that same day, interview with Administrator Pink starting at 1:15 p.m. confirmed what R1 stated. Thus, the allegation of facility failed to return resident's personal belongings is deemed unsubstantiated. Lastly, regarding the Facility failed to issue a refund. During interview with R1 at 10:29 a.m., R1 stated that the facility was paid for the January and February months. R1 lastly added that they have not requested a refund from the facility. Based on evidence gathered, the allegation is deemed unsubstantiated at this time. Exit interview conducted and a copy of the report was provided.