complaint·February 6, 2023

On 11/01/2022, 12/01/2022 and 12/02/2022 LPA Ivey Canady requested and reviewed medical documents, performed file review, performed Community Care Licensing (CCL) incident document search, and interviewed witness. On 11/01/2022, LPA requested all incident report documents from facility dated back 6 months. Based on this request and review, CCL did not receive an incident report regarding R1 ulcer wound. According to record review, on 8/11/2022, facility documented treating an ulcer wound on R1. Based on witness statement, document reviews, medical document reviews, interviews with witness, CCL incident document search, and documentation submitted by witness, the facility failed to report R1 pressure injury status to Community Care Licensing (CCL) and R1 responsible party as directed in Title 22 Regulations. Therefore, the allegation Facility did not notify family or CCL of incidents is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with Administrator. Appeal rights and report given On 12/2/2022, LPA discovered during continued interviews with RP, R1 was transferred from Skilled nursing in July 2021 to this facility. According to medical record review, facility chart notes, staff files and interviews with facility staff, R1 was being treated for a pressure injury on 9/1/2022 and did not come to the facility with the ulcer wound in July 2021. R1 has not been residing at any other location but this facility since admission. Based on review of medical files, chart notes and staff interviews, R1 has a diagnosis of pre - diabetes. Based on resident medical record review and Department consultation with licensed medical professional R1 ulcer wound is not related to pre-diabetes. According to review of medical reports, physician reports and staff interviews, R1 developed an ulcer wound while in the care of the facility. Therefore, the allegation; Facility neglected resident causing resident to obtain ulcer wound is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with Administrator. Appeal rights and report given. On 11/21/2022 LPA Ivey Canady visited the facility and met with facility administrator. LPA requested and received staff chart notes, medical files, and resident files for R1, R2 and R3. According to review of medical files, R1 attended all appointments as scheduled. According to review of staff files and chart notes, R1, R2 and R3 were given medications as prescribed. Based on detailed documentation by the facility, LPA reviewed evidence of efforts by the facility to provide R1 with prescribed medical assistance with medical equipment, daily as prescribed. However, on each daily prescribed occasion R1 refused the use of prescribed medical equipment. Subsequently, facility fulfilled Title 22 regulations regarding providing medical assistance as prescribed. Therefore, the allegation Facility is not following physicians orders is UNFOUNDED. Due to the information gathered LPA finds allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview held and a copy of the report was provided to Administrator Caleb Summerhays via email due to printer malfunction.