complaint·February 14, 2022

Interviews and records review revealed that R1 was admitted to this facility on 7/6/2021 and was discharged on 7/10/2021. Prior to being at this facility, R1 was in a skilled nursing facility from 6/25/2021 through 7/6/2021 due to a fracture. The Physician’s Report, dated 7/5/2021, noted that R1 had discoloration on the left and right heel. The review of the skilled nursing discharge paperwork did not note any wounds; however, there were instructions regarding wound care for both heels. R1 was not receiving hospice care services. Interviews with the Administrator revealed that the Administrator was aware of R1’s pressure injuries upon admission to the facility but was unaware of the exact staging. The Administrator claimed that R1 was receiving home health services yet stated that they did not communicate with home health regarding the status of R1’s condition, nor did staff receive training regarding proper wound care. The Administrator admitted that R1 was ’heavy’ and that staff had difficulty repositioning R1 as frequently as needed. The Administrator claimed that R1 was moved ‘more than twice a day’. Staff interviews revealed that at least one staff whom cared for R1 during R1’s stay was unaware of any pressure injuries but claimed R1 was repositioned when R1 was being cleaned. Staff whom did not provide care for R1 denied receiving training on proper wound care but claimed knowing that residents should be repositioned every two hours. A review of facility charting notes revealed that upon admission on 7/6/2021, it was noted that R1 had discoloration on both heels, yet it was written as follows; ‘No instruction yet from doctor/nurse for heel treatment’. Notes revealed that on 7/8/2021, a home health nurse came to evaluate R1, and that R1’s heels were treated with iodine and covered in gauze. However, an interview with a home health representative and a review of home health notes revealed that R1 was only evaluated on 7/8/2021 yet never received care. Charting notes revealed that staff applied iodine on both heels and changed the dressing, noting that R1 was in pain. However, on 7/10/2021, R1 became unresponsive and 9-1-1 was called. A review of medical records revealed that on 7/1/2021, R1 was bought into an emergency department due to increased confusion. Yet upon admission to the hospital, it was documented that R1 had unstageable bilateral heel pressure injuries. Based on the information obtained, staff did not conduct a proper assessment prior to admitting R1 to this facility, resulting in this facility retaining a resident with a prohibited health condition. In addition, staff admitted to not having instruction for proper wound treatment for R1. R1 was admitted to the hospital on 7/10/2021, and the injuries to both the left and right heel were unstageable bilateral pressure injuries. There is sufficient evidence to support the claim that the staff did not conduct a proper assessment prior to admitting R1 to this facility, thus retaining R1 with a prohibited health condition. This allegation is deemed Substantiated at this time. The LPA reviewed the findings with Ms. Fahimi. Ms. Fahimi communicated that they were not comfortable signing the report due to the contents of the report, and felt it was best for Administrator Galina Melkonyan to sign. Ms. Fahimi allegedly spoke with Administrator Melkonyan over the phone, whom disagreed with the findings and instructed Ms. Fahimi to not sign the report. Ms. Fahimi communicated to the LPA that had Ms. Melkonyan been available to receive the report, that Ms. Melkonyan would also refuse to sign the report. The LPA explained that signing the report indicates that the report was received by the Facility Representative, not that the Facility Representative agreed with the contents of the report. The LPA stated that the facility could still exercise their appeal rights. Ms. Fahimi communicated understanding, yet claimed that they did not want to sign the report. A Civil Penalty in the amount of $500 was assessed during today's visit, due to admitting and retaining a resident with a prohibited health condition. The prohibited health condition was not cared for by an appropriately skilled professional while at this facility. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Facility Representatives refused to sign the report. A copy of the report and appeal rights were provided to Ms. Melkonyan via email.