complaint·January 20, 2023

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver the findings of the above allegation. LPA met with Caregiver Elsie Viray and toured the facility. The investigation included interviews with staff, medical personnel, Resident One (R1), and a review of facility records and medical documentation. Licensee Charles Campbell arrived inside the facility at the time of visit. Regarding the allegation, “Resident sustained multiple pressure injuries while in care.” It was alleged that R1 was admitted to the facility on 10/1/2021 with a tiny open sore (pressure wound) but it was healing. On, or about 11/15/2021, R1 had open sores (pressure wound) on the buttocks, ears, ankle, shin and legs. Through information obtained via confidential interviews and document review, R1 was admitted to the facility on 10/1/2021 with a wound that required positioning/rolling. R1 was residing at an assisted living facility prior to moving to Campbell’s Loving Home. On 9/26/2021 the prior facility conducted an assessment and found that R1 had a pressure wound and required wound care. Wound care was ordered by the physician; however, R1 moved before wound care could begin. The assessment also indicated R1 required “substantial/maximum assistance rolling left/right.”. On 10/1/2021, five days after the assessment at R1’s prior facility, R1 moved to Campbell’s Loving Home. A review of the pre-admission appraisal did not indicate the presence of a pressure wound. Further, a Needs and Services Plan was not developed by the Licensee at the time of admission. Based on this information, R1 went without wound care from 9/26/21 until 11/12/2021. Interviews with a medical professional indicated the wound on R1’s coccyx was a stage 1, at best; however, two other wounds had developed. A wound to R1's ankle was seen to develop to a stage 4 and R1's ear had a wound that developed to a stage 3. The Licensee stated the family was contacted to inform them of R1’s condition; however medical treatment was not sought out by the Licensee. Therefore, based on the investigation, the allegation that Resident (R1) sustained multiple pressure injuries while in care is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Licensee was cited via Title 22. An exit interview was conducted and a copy of this report was discussed with and provided to Licensee Charles Campbell along with copies of the LIC9099-D, and Appeal Rights.