complaint·November 5, 2024

On 3/22/23 R1 was admitted to the facility, on the same day R1 initiated hospice care services. The same day, upon admission hospice nurse noted R1 exhibit Deep Tissue Injuries (DTI) and moisture associate with skin damage (MASD). On 3/29/23 additional DTIs were noted by hospice nurse. On 4/5/23 additional DTIs were observed by hospice nurse and wound care specialist was contacted. On 4/5/23 wound care specialist visited R1 and noted stage 3 and stage 4 wounds. Interviews conducted with staff revealed staff became aware R1 developed wounds. Staff were familiar with and instructed by hospice nurse to reposition R1 at least every two hours. Interviews with R1’s family members revealed, they had noticed that at the beginning it was difficult for the facility to provide care due to R1’s declined condition. However, family members felt that within a week facility staff was providing proper care and repositioning R1 as needed. Documents reviewed revealed R1 initiated hospice due to cognitive impairment, there are no other health conditions or health history noted. Hospice visits notes noted hospice nurse had provided training to facility staff and recommended R1 was reposition every two hours. Facility maintained a reposition log, per monthly reposition logs maintain between 3/29/23 to 4/5/23, R1 was reposition no more than between 1-3 times per day in a 24-hour period. Therefore, this allegation is substantiated. Based on LPAs interviews which were conducted and document records review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 developing stage 3 and 4 wounds in a period of 7 days due to lack of repositioning as directed by hospice staff while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Claudia Almeida and a copy of this report, LIC 9099D, and appeal rights were provided. Hospice nurse noted R1 was observed with Deep Tissue Injuries and moisture associate by skin damage MASD by hospice nurse, upon initiating hospice on 3/22/23. Between 3/29/23 to 4/5/23 R1 developed stage 3 and stage 4 wounds which were noted by a wound specialist on 4/5/23. Interviews conducted with staff revealed R1 moved into the facility under hospice care services due to R1’s health condition and family’s wishes. Facility staff stated R1 was provided care by a hospice nurse and the facility’s staff for all activities of daily living. Per family members R1 had declined in health and needed more assistance. Documents reviewed revealed R1 was under hospice care prior to move into the facility. However, R1 was discharge from hospice on 3/20/23 due to R1 plateauing in health. R1 moved into the facility on 3/22/23 under a new hospice care service agency which provided care from 3/22/23 to 6/28/23. R1 passed away at the facility on 6/28/23 while a hospice care nurse was by R1’s side. Death certificate issued on 2/14/24 notes R1 passed away due to natural causes. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Staff did not change resident’s diaper in a timely manner . It is alleged caregivers were to check R1’s diaper every 2 hours day and night and staff did not do it. Interviews conducted with staff revealed, it is facility’s practice to change residents to check and change residents as needed. Staff stated R1 was being change at least every two hours or more often when necessary. Family members did not have concerns about the care that was being provided by the facility. Facility maintains a monthly diaper change log, per March and April 2023 logs resident was changed an average of 3-4 times in a 24 hour period. There is not enough evidence to say that R1 require changing more than the times noted on the logs reviewed. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Claudia Almeida and a copy of this report was provided.