complaint·April 9, 2025

Regarding the allegation “Staff do not treat residents with dignity or respect” it was alleged multiple staff yelled at a resident. Interview with R1 revealed they were treated respectfully by staff, but they overheard Staff #1 (S1) and Staff #2 (S2) yelling at Resident #2 (R2). R2 was not available for interview. LPA interviews with three (03) out of four (04) residents revealed staff treat residents with respect and do not yell. Interview with the administrator revealed staff yelled to R1 and R2 because they were hard of hearing. Interview with Staff #1 (S1) at 9:30 a.m. on 04/01/25 and Staff #3 (S3) at 9:40 a.m. on 04/01/25 confirmed that staff increase their volume of speech when talking to residents who are hard of hearing. LPA did not hear any yelling or name calling during visits on 04/01/25 and today. Based on observations and interviews, staff treat residents with respect. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided. Interview with the administrator and staff #1 (S1) revealed R1 was hospitalized in February 2025 due to developing a prohibited health condition; a Stage 3 pressure injury. A few days later, R1 was readmitted back to the facility with the same condition with physician orders to reposition R1 every 2 hours. R1 received home health services to care for the pressure injury about three (03) times a week. Caregivers tried to assist R1 in repositioning and caring for their injury, but R1 always refused care. The Administrator and staff revealed that they had knowledge that R1’s pressure injury(s) was/were not healing and continued to be Stage 3. Interview with R1 revealed no staff assisted them with caring for their pressure injury. Interviews with other residents revealed no pertinent information to R1’s wound care. Interview with V1 confirmed R1 was non-compliant with staff care and refused treatment. V1 also noted that R1 was soiled with urine and feces during multiple visits. A review of R1’s preplacement appraisal and medical assessment revealed they were admitted to the facility on 09/24/24 with a Stage 1 pressure injury on their coccyx. Review of R1’s medical records revealed that on 02/05/25, R1 had a new and unstageable wound on their left buttock. A wound consultation from 02/14/25 revealed R1 was diagnosed with a Stage 3 pressure injury on their sacrum. R1 was hospitalized on 03/26/25 with a Stage 4 pressure injury on their sacrum. The facility did not have any home health records available. Based on record reviews and interviews, staff were aware of R1’s prohibited health condition which got worse due to R1’s noncompliance and lack of care. Furthermore, the facility readmitted R1 back with a Stage 3 pressure injury without doing proper reassessment. Therefore, based on overall investigation, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the LIC 9099-D page. A $500 immediate civil penalty is assessed today for a violation resulting Immediate hazard to health and safety of resident to R1. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights discussed. Copy of report provided.