Follow-up on corrections·July 24, 2023

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit following a Department Complaint Investigation on 6/11/2020, complaint control number 18-AS-20200605103755. During the investigation, the Department found that R1 was not provided with the care and services needed to meet R1 needs. R1 was admitted to the facility in 2016. Physician assessment completed in 2019 indicates that R1 had dementia and a history of skin breakdown. Per additional records review and staff interviews, R1 needed assistance with all activities of daily living (ADLs) such as bathing, dressing, toileting, medication administration. R1 was also considered non-ambulatory and used a wheelchair for mobility. On January 2, 2020, R1 sustained an injury to lower left shin while being transferred by staff from wheelchair to bed. First aid treatment was done. According to facility records, on January 21, 2020, a physician determined the injury as a Stage III pressure injury (wound). Referral was made for wound care. On January 30, 2020, R1 returned from physician’s office, and it was indicated that R1 was to see home health soon. When interviewed, facility staff reported being unaware if R1 was placed on home health for treatment of the wound. In addition, a review of facility records revealed no evidence to support that R1 received wound care from home health. As a result, it is determined that facility staff failed to ensure that R1 was provided with the care and services needed to meet R1 needs. From at least January 21, 2020, until February 5, 2020, when R1 was admitted to the hospital due to poor oral intake, R1 did not receive home health treatment as needed to meet R1 needs. During today’s visit, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Brittney Martinez, along with a copy of LIC809D and the appeal rights.