complaint·January 23, 2025

The investigation revealed the following: Regarding the allegation “Resident developed a Stage 3 pressure injury while in care”, it is being alleged that staff do not reposition Resident 1 (R1) as instructed by medical professionals which resulted to R1 developing prohibited health conditions. Records reviewed revealed the following: On 4/29/2024, R1’s Physicians Report does not mention pressure injuries or states “No” under “History of Skin or Breakdown.” On 05/01/2024, R1 was admitted to the facility; R1’s Preplacement Appraisal does not mention pressure injuries or history of skin breakdown; R1 was admitted to Home Health and was assessed by a Home Health Registered Nurse and noted no wounds and skin intact. On 05/03/2024, Home Health Record noted a sore on R1’s buttocks the Home Health nurse “instructed caregivers to reposition every 2 hours” and facility staff verbalized understanding; R1 was placed on an “individualized emergency plan.” Home Health Records indicate that Home Health nurses consistently advised facility staff to turn and reposition R1 every two hours, maintain skin clean and dry at all times, and advised them on the importance of movement and mobility for circulation, reduce prolonged exposure to pressure and facility staff (S1, S2, S3, and S4) “verbalized understanding or teachings and instructions.” between 05/03/2024 to 10/05/2024. Home Health Records indicated that on 06/25/2024, R1 developed stage 2 pressure injury to the buttock region and nurse provided staff with education on prevention with pressure wounds. Facility Records indicated that care was not being provided to residents between 8:00 PM to 7:00 AM seven days a week during the months of September 2024 and October 2024. On 09/04/2024, Home Health Records reveal that R1 acquired new wounds on inner leg, right foot heel, bruises to buttocks, and arms are swollen; Home Health Records describe R1 as having seven wounds. Hospital Medical Records indicated that on 10/08/2024, R1 was diagnosed with stage 3 pressure injury on left heel measuring 1.4cm and an unstageable pressure injury on his right heel, measuring 2x1.5x0.1cm. Interviews conducted revealed the following: On 10/17/2024, Four residents indicated that facility staff does not check in on them from 2:00 AM to 6:00 AM. One resident explains that staff tells them to request their needs before 7 PM because after 7 PM they will not assist. Staff 1 indicated that Home Health “Nurses advised them to reposition R1 every two hours.” Staff 2 indicated that “no one would reposition R1 overnight. S2 explained that “at that time, we don’t have a night shift.” Interviews with facility staff revealed that care is not being provided to residents between 8:00 PM to 7:00 AM seven days a week upon their hire dates in 2023 up until 10/14/2024. Interviews with Home Health staff indicated that facility caregivers were “instructed…to keep R1 clean and dry and to reposition R1 every two hours, “around the clock” and added that, “the pressure injury never fully resolved because R1 was not consistently repositioned or kept clean and dry.” On 10/09/2024, Registered Nurse-Wound Care Nurse saw R1 at the hospital and they explained “that incontinence causes MASD (Moisture-Associated Skin Damage) wounds and that not being turned/repositioned would contribute to pressure injuries.” Regarding the allegation “Resident developed a Stage 3 pressure injury while in care”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on records reviewed and interviews conducted in accordance with the California Code of Regulations, Title 22, please see LIC9099D. An immediate $500 Civil Penalty assessed, please see LIC421. Enhanced Civil Penalty: 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.” An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the Administrator, Angelique Gradney.