Complaint·March 21, 2024

Allegation #1 : Resident sustained a pressure injury while in care. This complaint alleges that R1 sustained a pressure injury while in care : the investigation revealed that Resident #1 formed a Stage III pressure injury on its coccyx beginning 08/23/21; and it quickly progressed to Stage IV by 09/02/21. Resident #1 had been receiving hospice care since 03/03/21 for an unrelated issue. Facility staff were instructed to reposition Resident #1 every two (2) hours due to the resident’s status of Bedridden. The wound worsened over the next week – while the resident continued to reside in the facility – with no new hospice care plan or wound training. The facility was directed to reposition Resident #1 every two (2) hours; but according to Witness #1 (Hospice Care Nurse), the reposition chart was not being followed; and, it had missing initials in spaces where the resident was supposed to be turned and its pressure injury was listed as Stage IV by 09/02/21. Resident #1’s health was in decline and the facility continued to retain Resident #1 with a prohibited health condition until its passing on 09/03/21. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Allegation #2 : Facility has roaches. This complaint alleges that the facility has roaches. LPA Calderon conducted an interview with A1. A1 expresses that residents have advised that there are roaches in certain rooms. A1 expresses that staff sprays certain rooms, and that pest control is called, and pest control company sprays the building and rooms for roaches and other bugs. LPA Calderon conducted an interview with S2-S7. S5, S6 and S7 have seen roaches in the building but expressed that pest control comes monthly and sprays for roaches. LPA Calderon conducted an interview with R1-R20. R2, R7 and R10 have seen roaches in their room. Residents called staff and pest control came out and sprayed their rooms. R1 and R13 have seen roaches in the dining room while eating food. Pest control came out and when the dining room was closed sprayed the dining room area. R4 states that R4 noted seeing roaches in the patio area. On 01/25/2023 LPA Calderon reviewed pest control paperwork that stated that pest control company sprayed roaches in the facility. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Allegation 3: Staff left resident in soiled diaper for extended period. This complaint alleges R1 diaper was not changed timely. LPA Calderon conducted an interview with A1. A1 expressed that R1’s incontinence care occurred 3 times per shift. A1 was unable to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. R1 was receiving hospice care for the pressure ulcer and pre-existing health condition; however, the facility failed to update the hospice care plan to reflect incontinence needs. LPA Calderon was unable to obtain documented incontinence care instructions and staff training for R1’s incontinence care . Based on interviews conducted and lack of records provided to support R1’s incontinence needs were met according to Hospice orders, LPA Calderon found sufficient evidence to support the above-mentioned allegation and finds this allegation “Substantiated”. Based on interviews, observations and supporting documents facility staff failed to ensure a physicians order/hospice care plan were in place to address R1 pressure injury by an appropriate skilled medical professional The preponderance of evidence standard has been met; therefore, the allegation of “resident sustained a pressure injury while in care” and “facility has roaches”, “Staff left resident in soiled diaper for extended period”, is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citations issued (ref LIC9099D) A face-to-face meeting was conducted with Administrator Janie Acosta, and a hard copy was provided. Allegation #1 : Staff did not administer the correct medication dosage to residents. This complaint alleges the facility failed to increase R1 medication dosage per a physician’s order. LPA Calderon conducted an interview with Janie Acosta (A1). A1 stated R1’s medications were administered per doctors’ orders. LPA Calderon obtained and reviewed R1’s Medication Administration Record (MAR) and found 7 out of 8 medications were not administered on 08/25/21 and 08/26/21. LPA Calderon was unable to find or obtain a record of a doctor’s order indicating a change in any of the medication dosages. LPA obtained and reviewed a PRN Authorization Letter dated 2/9/21 and signed by the Hospice Medical Director. The PRN Authorization Letter states Hydrocodone Bitartrate and Loperamide can be taken added to R1’s PRN’s. These medications were found in the PRN section on R1’s MAR. LPA Calderon conducted an interview with 3 Staff members who handle Resident medications. LPA Calderon conducted interviews with 6 staff members. LPA found 6 out of 6 staff members did not report medication dosage issues. LPA Calderon conducted an interview with 20 Residents. LPA Calderon found 3 out of 20 Residents stated having experienced issues with medication administered; however, corrections were made, and issues resolved by the facility. LPA Calderon found 17 out of 20 Residents have not experienced issues with medication administered. Based on records obtained and interviews conducted, LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”. Allegation #2 : Staff leave food in residents’ room for extended period. This complaint alleges that staff leave food trays in R1’s room and this is contributing to a roach problem. LPA Calderon conducted an interview with A1 who expressed that R1 receives tray service for all meals as R1 is bedridden. A1 stated staff will retrieve the food tray 3 times per day from R1’s room. A1 stated that roaches have been present in the facility and pest control is employed for this reason. LPA Calderon conducted an interview with Staff S2-S7 and found 3 out of 6 staff expressed that some residents prefer to eat in their rooms and food trays are retrieved from the Resident rooms timely. S5-S7 expressed that S5-S7 follows up with dining staff to make sure food trays are picked up timely. LPA Calderon conducted interviews with Residents R2-R20 for complaint and found 19 out of 20 residents either received tray service and expressed tray pick-up occurred timely or eat meals in the facility dining room; therefore, they were unable to speak to the timeliness of tray retrieval by staff. , LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations “staff did not administer the correct medication dosage to resident” “staff leave food in residents’ room for extended period” did or did not occur, therefore the allegations is UNSUBSTANTIATED. A face-to-face meeting was conducted with Administrator Janie Acosta A1, and a hard copy was provided.