complaint·April 19, 2024

On 04/04/24, LPA Maldonado made a subsequent visit and met with Executive Director, Laura Rodriguez. During the visit, LPA obtained a copy of the resident and staff rosters, and conducted interviews with Staff# 8-14 (S8-S14), and Residents# 2-7 (R2-R7). LPA also obtained copies of the following documents for R2-R7: Facesheet, Physician's Report, and Needs and Services Plan. LPA was unable to interview Resident#1 (R1) due to R1 deceased. The investigation for the above-mentioned allegation was conducted by the department. The investigation consisted of the following: Interviews conducted with Staff#1-7 (S1-S7) and Witness# 1-2 (W1-W2), and obtained the following records for R1: Facility Service Plan, Resident Assessment, Individualized Service Plan, facility Assessment Notes dated: 08/08/22, 09/12/22, and 11/25/22, facility shift reports, facility Communication notes from Hospice, Hospice Care Notes, Transfer/Discharge report from Skilled Nursing facility, Hospital records dated 12/14/22. R1 was not interviewed due to R1 deceased. The investigation revealed the following: Staff did not follow resident's care plan resulting in resident obtaining a prohibited health condition. It is alleged that per R1's care plan, R1 was required to be repositioned every (2) hours, however staff did not follow the care plan, which lead R1's Stage I pressure wound to become a Stage III pressure wound. Per the investigation, R1 sustained a fall at the facility in November 2022 which resulted in a hip fracture. Following surgery from the fracture, R1 was at a skilled nursing facility where R1 developed a Stage I pressure wound on the buttocks due to R1 becoming bedridden. Per R1's updated facility service plan, dated: 11/25/22, R1 had a change in condition which required R1 with hands on assistance for repositioning in bed due to becoming bedridden. Per staff interviews, (7) of (7) staff stated that R1 was repositioned as per R1's care plan. However, R1 was repositioning self onto R1's back after being repositioned by staff. Per records review, it was discovered that the facility did not update R1's care plan to address R1 repositioning self back after being repositioned by facility staff, which led to R1's Stage I pressure wound becoming a Stage III pressure wound. Therefore, this allegation is Substantiated. Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on LIC9099-D. Immediate Civil Penalties in the amount of $500 will also be issued. An exit interview was conducted and a copy of this report, and appeal rights were provided. The following allegation was investigated by the department: Resident in care sustained multiple falls resulting in a hip fracture while in care. The investigation consisted of the following: Interviews conducted with Staff#1-7 (S1-S7) and Witness# 1-2 (W1-W2), and obtained the following records for R1: Facility Service Plan, Resident Assessment, Individualized Service Plan, facility Assessment Notes dated: 08/08/22, 09/12/22, and 11/25/22, facility shift reports, facility Communication notes from Hospice, Hospice Care Notes, Transfer/Discharge report from Skilled Nursing facility, Hospital records dated 12/14/22. R1 was not interviewed due to R1 deceased. The investigation revealed the following: Regarding allegation: Resident in care sustained multiple falls resulting in a hip fracture while in care. It is alleged that R1 had multiple falls while in care at the facility, which resulted in R1 sustaining a hip fracture that required surgery. Per the investigation, R1's first documented fall occurred in November 2022. The fall that occurred at that time resulted in R1 sustaining a hip fracture. Per R1's Pre-Placement appraisal and Individualized Service Plan, R1 was not a fall risk at this time. R1 returned to the facility on 12/09/22 and was placed on hospice to receive wound care due to R1 being bed bound and sustaining wounds while in a skilled nursing facility, following recovery from the hip surgery. Per R1's hospice records dated 1/20/23, 1/30/23, and facility shift reports dated 1/20/23 and 1/26/23, it was noted that R1 was found by caregivers on the floor, tangled in R1's blankets with no visible injuries. From 2/07/23 through 2/10/23, R1's family hired a private caregiver through a home health company to provide 1:1 care to R1 during the night, as it was noted that R1 was getting up at night and sustaining more frequent falls. Per staff interviews, (7) of (7) staff stated they did not witness R1's falls. R1 was found on the floor during their regular status checks. Staff also stated that due to R1's falls were becoming more frequent due to R1's progression of R1's cognitive impairment. The allegation suggests that the multiple falls culminated in the resident sustaining a hip fracture. There was no evidence to prove that R1 was a fall risk prior to the fall that resulted in a hip fracture. Therefore, this allegation is Unsubstantiated. On 04/04/24, LPA Maldonado made a subsequent visit and met with Executive Director, Laura Rodriguez. During the visit, LPA obtained a copy of the resident and staff rosters, and conducted interviews with Staff# 8-14 (S8-S14), and Residents# 2-7 (R2-R7). LPA also obtained copies of the following documents for R2-R7: Facesheet, Physician's Report, and Needs and Services Plan. LPA was unable to interview Resident#1 (R1) due to R1 deceased. (Report Continued on LIC9099-C...) During the visit, LPA Maldonado investigated the following allegations: Resident fell and was left unattended on the floor for an extended period of time. Resident is not being transferred out of bed by staff on routine basis. Staff are not assisting resident with oral hygienes & dressing. Regarding allegation: Resident fell and was left unattended on the floor for an extended period of time. It is alleged that on 1/19/23, R1 fell out of bed and was found on the floor by facility staff about (3) to (4) hours later, on 1/20/23. Per incident reports dated 1/20/23, R1 was found on the floor at 1:45AM during status check rounds conducted by facility staff. It was noted that R1was assessed for injuries and assisted back into bed. At 4:45AM, during status check rounds, facility staff found R1 on the floor again. R1 was assessed for injuries again and was assisted back into bed by staff. Per staff interviews, (7) of (7) staff denied the allegation. Staff stated that R1 was getting up at night more frequently, so R1 was placed on status checks every (2) hours. There is insufficient evidence to prove the amount of time R1 was on the floor for before staff found R1 while conducting their status checks. (6) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Resident is not being transferred out of bed by staff on routine basis. It is alleged that R1 is not being transferred out of bed on a routine basis and as a result, R1 is becoming more contracted. Per hospice records dated 2/04/23, R1 was to be assisted with repositioning every (2) hours due to a pressure ulcer on R1's coccyx and R1 being bedbound, and required assistance with transferring out of bed/chair. Per medical and hospice records, there is no indication that R1 was contracted. (7) of (7) staff interviewed denied the allegation. Staff stated that residents who require repositioning and assistance with transfers are assisted as required and as needed, based on their care plans. During interview with R2, R2 reported that staff come in frequently to assist with repositioning and transferring, as they require it. (5) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff are not assisting resident with oral hygienes & dressing. It is alleged that the facility is charging R1 an excessive amount of fees to provide services that R1 is not receiving, such as providing oral hygiene twice a day and assisting R1 with changing clothes daily, as R1 was found in only a shirt and briefs during the fall incident on 1/20/23. (7) of (7) staff interviewed denied the allegation and stated that R1 and other residents who require assistance with oral hygiene are assisted (2) to (3) times a day. (Report continued on LIC9099-C...) Staff stated sometimes residents may deny the care, however they will attempt at a later time and encourage them to complete the care. If residents continue to deny, it is charted and communicated to the staff on the incoming shift so that they may offer residents the care again. During interview with R2, R2 stated that staff assist R2 with oral hygiene care, changing clothes, and incontinence care frequently. (5) of (6) residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and a copy of this report was provided.