complaint·October 10, 2024

The investigation consisted of LPA interviewing five (5) residents (R#2-R#6) , R1 was not available for LPA to interview. LPA interviewed three (3) staff (S#1-S#3) and reviewed the following documents, staff roster, resident roster, and for three (3) specified residents: resident face sheet, MAR log for July, August September 2023, physician’s report, most recent incident report and appraisal needs & services, Noyan Home Health records, facility progress notes, R1 hospital records. R1 LIC602A for R1 dated 01/19/2022, 11/02/22, and 04/12/2023 The investigation revealed: Regarding Allegation: Staff neglected resident's wound in care LPA interviewed three (3) staff and three of three (3) staff denied the allegation. LPA interviewed five (5) residents and five (5) of (5) residents could not corroborate the allegation. According to records reviewed and obtained, R1 was admitted to facility on 01/17/2022 and at that time, records show that R1 had skin intact without any open wounds. According to medical records, R1 wound care was ordered by Medical Doctor on 06/15/2023. Review of Home Health records show that R1 had developed a stage 4 wound by 06/30/2023. Department review of Noyan Home Health records indicate that resident refused wound care on the following days: 07/01,02,03,04,06,07,08,09,13,15,16,18,20,22,23,27,29,30th. According to records reviewed, R1 also refused wound care for days in August and September 2023. S2 stated she discussed R1 refusal of wound care with Administrator S1 and mentioned to Administrator S1 that resident required higher level of care. Both S1 and S2 admitted to the department that R1 refused wound care while at the facility. S1 admitted to the department that the facility is no longer able to meet R1 needs due to his high-risk behavior that causes safety concerns and R1 requires a higher level of care elsewhere. Under the admission agreement, the facility should have notified R1 physician and/or other appropriate persons regarding his change in condition and refusal of wound care treatment. R1 basic services under the facility admission agreement were not met. R1 actions could have possibly met the criteria for eviction under the admission agreement, but the administrator, S1, chose not to do anything about it and continued to house R1 at the facility, making him a risk to himself and others. By retaining R1 at facility, facility neglected R1 wound care. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. The facility has been informed that Immediate civil penalty is being issued during today’s visit in the amount of $500.00, based on health and safety code 1569.49. “The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). “ Exit interview was conducted with Lydia Pabion, Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.