Complaint·July 1, 2021

once they were proficient, the PEC nurse scaled their visits back to once a month to check on R1 vital signs and conduct a head to toe assessments. Interviews conducted concluded that the PEC nurse instructed facility staff to contact them with any new medical issues or changes in R1’s condition. The investigation revealed that in Mid-February 2021, staff noticed the developments of wounds on R1 heels and reported it to Administrator Noemi Figueroa. At the time, Administrator Noemi Figueroa noticed R1 was rubbing their heel against the mattress, causing it to become red. The observations were reported to Cal Optima Home Health. Administrator Noemi Figueroa was advised to reach out to R1’s responsible party and inquire about getting an air mattress. Although she could not recall the exact date, Administrator Figueroa reported that R1’s family provided a new air mattress sometime after February 26, 2021. Administrator Noemi Figueroa stated that R1 continued to rub their heels on the mattress after receiving the new air mattress. Administrator Noemi Figueroa first noticed R1’s heel injuries on March 4,2021 and she described them as red with blistering. Administrator Figueroa admitted she did not call the home health to notify them of R1 wounds and home health had not been out to the facility to visit R1. Administrator Noemi Figueroa and facility staff were aware of R1 developing and worsening wounds on both of their heels and did not report the wounds to R1 home health nurse or treating physician. The investigation revealed that on March 8,2021, a PEC nurse went out to the facility to conduct their monthly assessment on R1, and that during the examination the PEC nurse discovered the wounds on R1’s right and left heels. Both wounds discovered by the PEC nurse were black in color and was identified as unstageable pressure injuries. Interviews with interviewees concluded that although staff tried to mitigate R1’s wounds by elevating their feet, changing their mattress and putting heel booties on, the wounds continued to worsen. Three of three Interviews with Interviewees concluded that R1’s heel wounds were never reported to home health officials by facility staff. From approximately February 26, 2021 to March 8, 2021 Administrator Figueroa did not seek medical attention for R1’s worsening wounds. Upon notice of the unstageable pressure injuries, Administrator Noemi Figueroa reported that she did not send R1 out to receive medical treatment as the home health nurse had reached out to R1’s primary care physician Continued on LIC9099-C who advised the home health nurse to begin treatment. No request for exception was received by the Department in order to retain a resident with a prohibited health condition of unstageable pressure injuries. Administrator Noemi Figueroa did not report that she notified the home health nurse of the condition’s prohibited status. Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “Facility retained resident with unstageable pressure injuries” and “facility failed to seek timely medical treatment,” has been met; Therefore, the allegations listed above are deemed to be SUBSTANTIATED. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Assistant Administrator Yulisa Figueroa, and a copy of this report, along with LIC9099-D, Appeal Rights, and the LIC 811, identifying confidential names was left at facility.