complaint·July 12, 2021

Allegation: Facility staff did not seek medical attention in a timely manner. During the course of this investigation, LPA interviewed Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). Interviewed Staff indicated R-1 received medical visits for wound care. Visits were conducted on 04/14/2020, 04/17/2020, 04/21/2020, 04/24/2020, 04/28/2020 and 05/01/2020. Per Facility Administrator, there is no visitor logs for R-1 other than the dates noted above. Per Facility Administrator, R-1 received televisit consultations prior to visits, however, Facility Administrator was only able to provide evidence of communication via text for 04/08/2020, 04/10/2020 and 04/11/2020. Facility Administrator was unable to provide evidence on any televisits nor visits prior to 04/08/2020. Per Facility Administrator, due to COVID-19, R-1 was only receiving tele-visits and visits to this home. Per Facility Administrator, S-1 was changing R-1's gauze and applying ointment since 03/29/2020 up until discharge. R-1 was admitted to this facility on 03/28/2020 from a Skilled Nursing Facility for wound care. Interviews and reviewed documentation corroborate this allegation. Allegation: Facility staff did not distribute residents medication as prescribed. During the course of this investigation, LPA interviewed Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). Facility Administrator indicated R-1 had ointment to be applied to the wound when R-1 was discharged from the Skilled Nursing Facility to this facility. Facility Administrator did not have any supporting evidence for this treatment/medication. Facility Administrator provided a prescription order for R-1 dated 04/21/2020 for ointment. There are no medication orders for wound treatment medication prior to 04/21/2020 on file. Interview and reviewed documentation corroborate this allegation. Allegation: Facility staff did not follow physicians orders. During the course of this investigation, LPA interviewed Facility Administrator and Staff #1 (S-1). LPA was unable to interview R-1 as R-1 is no longer residing at this facility (discharged on 05/01/2020 as R-1 required a higher level of care). Per Facility Administrator, S-1 was changing R-1's gauze and applying ointment since 03/29/2020 up until discharge. R-1 was discharged from this home on 05/01/2020. Per R-1's file review, there were no orders on performing routine wound care prior to 04/14/2020. Interviews and reviewed documentation corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiency as per California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D . An exit Interview was conducted with the Administrator, a copy of this report and Appeal Rights were provided