Follow-up on corrections·April 3, 2025

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Chateau at River’s Edge RCFE on 4/3/25 at 9:00am to conduct a case management deficiencies inspection to address deficiencies observed in the process of conducting a complaint investigation regarding R1 (see confidential names list, LIC 811 dated 4/3/25). In the course of the department’s investigation, the department identified the facility did not meet title 22 regulations for providing timely medical assistance for R1 as their bilateral injuries to both thighs were not in a state of healing and were in fact worsening. The facility documented concerns regarding R1’s wounds on 8/9/23. On 8/12/23 and 8/13/23, facility staff attempted to reach Home Health nurse responsible for wound care and on both dates there was no response from home health and no visits conducted to address worsening wounds. On 8/17/23 facility nurse notes identified wounds continuing to deteriorate. R1 was not transported to be evaluated at the hospital until 8/21/23 at the advice of R1’s physical therapist who observed a foul odor emanating from R1’s wounds. Additionally, the home health and wound care order in place for R1 when they returned from skilled nursing on 7/24/23 was for a surgical wound on the hand/wrist. On 8/1/23 Home health was initiated, and no pressure injuries are noted. On 8/7/23 R1’s physical therapist observed two (2) “large wounds on buttocks” and R1 should have been re-evaluated for a change in condition. The facility did not have R1 re-evaluated. The department has also concluded the facility did not put in place any interventions to prevent worsening of wounds on R1’s thighs from prolonged sitting on the toilet seat such as a padded toilet seat or timed toileting to prevent R1 from prolonged sitting as well as sitting for extended periods of time in their wheelchair. The department has also concluded the facility not mot meet the requirements for basic services provided to R1. The department obtained evaluations and needs and services plans dated 7/22/23 that R1 requires “extensive” assistance for toileting. Multiple Home Health agency staff observed R1 on the toilet with no staff members present or aiding R1 who demonstrated sitting on the toilet for prolonged periods of time without intervention or assistance from staff members. Statements obtained from the administrator at the time of the incident described the resident as mostly independent. Per R1’s appraisal on 7/22/23 R1 was documented as needing standby assistance from staff members while toileting. Per California code of regulations, Title 22, the following deficiencies are cited during today's inspection. Due the violation resulting in an injury to the resident, an immediate civil penalty is issued and the department will evaluate the deficiency for additional civil penalties. Exit interview conducted and a copy of this report and appeal rights are left at the facility.