Complaint·September 7, 2023

Allegation: Resident sustained visible abrasion, bruises, and wounds while in care. It is alleged that facility caregivers neglected resident (R1's) care because abrasions, bruises, and wounds evaluated by medical personnel indicated the injuries were not recent and had been there a while. Based on DSS Investigator Laura Garcia's investigation, the findings indicate that facility caregivers staff (S1) and (S2) neglected to provide adequate care for resident (R1) because they were not aware of the severity of resident (R1's) injuries. According to caregiver staff, the resident displayed signs of early Dementia and had aggressive behaviors, which made it difficult for caregivers to provide incontinence care and assist Activities of Daily Living (ADL's) i.e. showers and dressing. Per staff interviews, the facility had staffing shortages at that time. Therefore, staff failed to meet the needs of resident (R1) and did not provide proper care and supervision. Furthermore, facility staff did not provide investigator notes and/or logs pertaining to resident (R1's) care, and were not able to give details of the plan of care, or R1's prior condition to injuries sustained. The resident was enrolled in home health or hospice care prior to this incident. On March 27, 2021, R1 was transported to hospital Emergency Room. Medical records indicate that the resident’s bruising was due to prolonged immobility, which reflects a lack of care and supervision as the facility knew R1 needed assistance with repositioning and transferring. The resident also suffered from sepsis, acute Urinary Tract Infection (UTI), acute cellulitis, and skin excoriations to back, RUE, right axilla, buttocks, multiple erythematous lesions to bilateral knees and shins. Based on records and photographs, there is enough evidence to corroborate the allegation. Allegation: Resident was found laying in feces. It is alleged that facility caregivers failed to provide incontinence care to resident (R1) because on March 27, 2021 at approximately 4:35 PM, resident (R1) was found on the bathroom floor naked, awake, with feces residue on waist, legs, and ankles covering the right side of the body. The resident was not able to get up on it's own. A body check assessment by law enforcement found the resident had feces residue on right palm, index finger, and thumb indicating the resident had not been bathe properly and/or cleaned after using the restroom. Per record review, the last appraisal (3/30/2021) indicated R1 had an increase in cognitive impairment related to short term memory with episodes of forgetfulness. Staff acknowledged that R1 had been recently transferred to the facility first floor due to requiring higher level of care. In addition, staff stated that they were not performing body checks on the resident, and would only knock on the door and make sure the resident was fine. Photograph evidence and interviews conducted supports the allegation. *****Administrator was informed that an enhanced civil penalty might be assessed based on H & S Code. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Per Title 22, deficiencies are cited. Exit interview was conducted with Brandie Mendibles. A copy of the report and appeal rights were provided.