complaint·April 25, 2022

On 10/07/2021 LPA Cardenas spoke with Hospice registered nurse, John Chen who indicates that R1 has a skin rash, it has not been confirmed that it is scabies. He states that there was no burrowing. Per the hospice instructions Dr. prescribed permethrin cream as a preventative measure, and he is only follow hospice protocol. On 4/22/22 LPA Cardenas spoke with Norwalk Community Hospital who indicates that resident was brought in with scabies treatment, however there is no confirmation that resident had scabies at time of admission. “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” Exit interview conducted and a copy of this report was provided to Melissa Flores. (cont pg 2) is ambulatory but has difficulty walking upstairs, R1 can get out of bed unassisted and is not a fall risk, resident has had two falls since being at facility. Per interview with S1, staff stated that she was getting residents ready to take them to the dinning room. S1 fixed R1s hair and left resident sitting on the bed; staff walked out of the room for five minutes and when she returned, she saw R1 on the floor by the door. R1 couldn’t communicate what happened. LPA Cardenas reviewed medical records from Norwalk Community Hospital, On 09/29/2021 R1 arrived to Norwalk Community hospital with left hip pain due to unwitnessed fall at the facility. X-ray hip and pelvis 2 views showed left femoral neck fracture, there are also nondisplaced fractures of the left superior and interior pubic rami. On 12/08/2020 R1 was admitted to Emergency room Chief complaint: Left arm pain, “patient apparently fell from bed at the facility 10 days ago.” On arrival the left arm is swollen. X-ray on the left humerus shows a fracture dislocation of the proximal humerus. LPA Cardenas reviewed R1’s facility records: Per Physician report dated 10/27/20 R1 primary diagnosis is Dementia, resident is confused, disoriented and non-ambulatory. Per most recent Appraisal on file is dated 4/18/19: R1 is Active but has difficulty climbing/ descending stairs, uses walker, Needs no special observation. Per Unusual incident report (UIR) on 9/28/21 S1 found R1 inside the resident’s bedroom on the floor. R1 was admitted to the hospital with a confirmed left hip fracture. Per UIR on 08/14/21 R1 fell out of chair while eating breakfast. R1 didn’t not have re-appraisal, it was not completed after residents’ hospitalization's for fall. Initial physicians report was completed 04/09/2019 and second physician report was completed 10/27/2020, Dementia residents should have a physician report completed every year. LPA Cardenas reviewed Steward Hospice Plan of care, R1 is recertified due to declining condition, R1 is diagnosed with Senile Degeneration of Brain. Continues to have a slow and steady decline in condition. R1 is very confused and is a fall risk (ongoing problem.) POA is notified regarding unusual gait. Recommended use of wheelchair during mealtime. Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted and a copy of this report and appeal rights provided to Melissa Flores. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1)