Complaint·December 1, 2021

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident requires a higher level of care. The complainant alleges resident #1 (R1) required a higher level of care. The complainant did not provide additional details on this allegation. Records indicate that there was no lack of care or supervision with (R1’s) care. Progress notes indicate that (R1) was reassessed each time she was returned from a hospital stay and interventions included repositing and changing every 2 hours. (R1) was readmitted to the hospital on 12/11/20. and was discharged 01/16/21. Medical records indicated during (R1’s) discharge that she would require a higher level of care and that the hospital will be responsible for an appropriate placement for (R1’s) care who eventually was placed on hospice care. Interviews conducted with residents #2-#11 all revealed that have no signs of any residents that require higher-level care. According to staff #1-#8 (S1-S8) there are no residents that are being retained at this facility that require a higher level of care that would violate Title 22 Regulations 87615 Prohibited Health Conditions. The facility continues to implement employee training programs that address the nature of these issues. Based on the information gathered, there is no evidence to support the allegation mentioned above. Allegation: Resident left in a soaked diaper and urine saturated dressing. It is alleged resident #1 (R1) was left in a soaked diaper saturated with urine. The complainant did not provide additional information on this allegation. The administrator (S1) stated caregiver’s responsibility is to assist the residents with activities of daily living (ADL). Caregivers could be responsible for up to 10 residents at one time. When a caregiver is notified of a diaper or bedding change, the caregiver will address the matter immediately. Moreover, caregivers are trained to use aided equipment to help maneuver residents who are heavy to clean them. (S1) claims in the situation with (R1) when admitted in 2015 was medically evaluated as independent health condition declined each time she was in and out of the hospital. (S1-S2) claims that (R1) was being assisted by caregivers (R1) was being assisted with diaper changes every two (2) hours and repositioned. (S2-S8) all verified residents are monitored at least three times during each shift within the eight hours. (S2) further asserted, it would be improbable to have (R1) in soiled diapers for more than (2) two hours as she was changed every two (2) hours. Interviews with residents #2-#11 (R2-R11) all claimed they had no problems with the staff and found them to be attentive and responsive to their care and needs. Evaluation Report continues on LIC 9099-C INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident has a worsening wound and pressure injury while in care. It is alleged resident #1 (R1) had a worsening wound and pressure injury while in care. The complainant claims that (R1’s) wound deteriorated and developed more deep tissue injuries. According to service records and (S2) Declaration, (R1) was sent to the hospital on 11/16/20 and returned on 11/17/20. During (R1’s) stay at the hospital, she developed a Stage 1 pressure wound. Despite all interventions including reposition and diaper changes, (R1)'s wounds developed to Stage 2 while at the facility. According to (S2) the facility made attempts for Home Health assistance and was unsuccessful. According to an incident report (R1) was readmitted on 12/11/20 at the hospital for further evaluation and intervention. (S2) reports there was no wound care plan in place when the facility was treating the (R1) for Stage 1 or 2 pressure injuries. According to medical records (R1) when admitted on 12/11/20 had pressure ulcer at Stage 4. An interview with (W1) stated that he was aware that (R1) had pressure injuries and was unable to determine the stage level as it was difficult to do an in-person visit during the COVID pandemic. An interview with (R1) claims she had pressure injuries while she was being cared for at the facility and it was painful. Based on interviews and physical evidence, there is sufficient proof to support the allegation mentioned above. Based on the Department's observation and interviews, records, and photographs reviewed, the preponderance of evidence standard has been met, therefore the allegation of "Resident has a worsening wound and pressure injury while in care" is found to be: Substantiated . California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. An exit interview was conducted with Reggie Jones. The Rights were discussed, and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report. Furthermore, (R2-R11) felt their care and supervision are being met and were complimentary of the staff. According to (S1) the staff went above and beyond what was expected and that (R1) was not charged additional fees for the additional services performed. An interview with (R1) could not recall if she was left in soiled clothing or diapers. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R1)'s service records, and interviews conducted and found no evidence to support the allegations: "Resident requires a higher level of care" and "Resident left in a soaked diaper and urine saturated dressing". Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Reggie Jones and a copy of the report was provided by email.