complaint·October 13, 2022

R1 sustained three skin tears as a result of staff improperly caring for R1. The Resident Care Director/LVN(S1) explained on how R1 sustained the three skin tears. On December 2021, R1 sustained a laceration on her left forearm when staff wheeled her into the dining room. The staff did not lift her arms before sliding her under the table causing skin on her arm to come off. On January 29, 2022, R1 got a large skin tear on her leg because one staff pulled R1 from her wheelchair to R1’s bed and her foot got caught at the end of the bed. R1’s leg bled so much that R1 was sent to the hospital and received four (4) stitches. On February 28, 2022, R1 sustained a skin tear on her elbow on the bathroom vanity while in the bathroom with a caregiver. R1 stated that facility staff are rough when handling her during transfers and during showers. R1 and W1 reported that the Resident Care Director/LVN(S1) at the time stated that the skin tear sustained on January 20, 2022 resulted from an agency caregiver. S1 further stated to R1 and W1 that they do not always have sufficient staff to provide the two-person lift that R1 requires. S1 and S2 were interviewed and both indicated that the facility lacks staff on certain days. According to the R1’s admission agreement, resident is paying for the highest level of care to live at the facility. R1 requires incontinent care, transfers to the dining room for meals, dressing and showers. W1 stated that R1 is left on the wheelchair often because she is a two person lift and they would leave in the wheelchair after bringing her up from the dining room. R1 sustained a Stage I pressure injury and home health agency for care. W1 stated that R1 is supposed to get regular checks from staff every two to three hours but was not receiving them. W1 stated that R1’s incontinent care has not been changed regularly every two to three hours or as needed. Staff would leave R1's diapers in the trash can and it was uncovered. The room smelled like urine. W1 stated R1’s room and bathroom are not cleaned regularly. On February 28, 2022, R1 sustained a skin tear on her elbow which resulted in bleeding. There was no staff who cleaned up the blood on the bathroom floor and vanity. The facility Administrator stated that the facility does not have any housekeepers for many months. Based upon review of records and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. See LIC 9099D for cited deficiencies per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted along with appeal rights were provided and a copy of this report was left.