complaint·October 25, 2024

A review of the Home Health dated 6/3/24 notes revealed a pressure injury at stage 2 (Left Thigh) which is allowed in residential facilities. However, it also revealed that R1 had a pressure injury at stage 3 (Right ankle) and a pressure injury at stage 4 (Coccyx) and (Lower Back), and a pressure injury which was unstageable (Right Thigh). A review of the hospital medical records dated 6/4/24, revealed R1 as non-verbal, Mid-back, stage 3, Sacrum, stage 4, Right hip, unstageable, Left hip, unstageable. LPA observed that R1 was not receiving hospice care services while residing in the facility. During an interview on 9/18/24 the Administrator stated the wound got worse within 2 weeks. Based on the Administrator being aware of the 5 pressure injuries 4 of which are deemed prohibited, this allegation is deemed substantiated. Regarding allegation, “Staff interfered with a resident's visitations”, A review of the Admission Agreement signed and dated 6/18/22 regarding visitation, LPA observed the visiting hours to be 9a – 7p requesting that all visitors sign in and be respectful to other residents and staff. After 8p or before 8a visits, they are requested to ring the doorbell. Administrator also asked if they could call as a courtesy so staff can expect them. Interviews revealed that R1 had visitors and was never refused. S1 stated that there was a visitor who wanted to see R1’s body and the visitor was told not to violate the residents’ personal rights. A review of documented “Texts” revealed that RP usually informs Administrator when visits will be conducted and who will arrive. Administrator was aware that a nurse was coming to assess R1. LPA observed an email from Administrator to responsible party indicating time to visit is 9a-1p and that after 4p is the staff’s busiest time. If there are special circumstances requiring visits during this time visits may occur after contacting staff in advance. On 5/20/24 at 9:20am the responsible party attempted to arrange a 6:30p visit via text and Administrator responded could it be before 3-4p because at 6:30p is too late for other residents and R1 goes to bed at 5p. The Administrator discovered it wasn’t family but other facilities looking to assess and was not aware the family was looking at other placement options and they were looking to no longer having resident at the facility. Based on visiting policy in the admission agreement which indicates the hours of 9-7p and Administrator admittance in stating no is evident that the administrator did not uphold the admission agreement visiting policy. Regarding allegation, “Staff did not seek timely medical attention for a resident”, LPA observed that on 5/30/24 a text revealed that Responsible Party mentioned a nurse would come to assess R1 and the physician will be contacted. On 5/31/24 the nurse was requested. On 6/1/24 Responsible Party stated in text a friend of family (nurse) will arrive on 6/2/24. On 6/2/24, the nurse and doctor indicated R1 may have pressure injuries and to repositioned. On 6/3/24 nurse and Responsible Party arrived at which time, the nurse staged the pressure injuries to be stage 4 and for R1 to be non-emergency transported to ER. Administrator suggested calling 911 rather than wait to transport for an hour. Based on information received from documentation and interviews, the following deems this allegation to be SUBSTANTIATED: -A review of text message on 5/20/24, the Administrator notified the responsible party regarding a wound on R1 -A review of the preplacement Appraisal dated 6/30/22 which indicated R1 is a risk of skin breakdown -Administrator was trying to manage the wounds instead of sending R1 to see a skilled medical professional. -R1 did not receive medical attention for the wound(s) until 14 days later. The investigation revealed that Administrator did not activate 911 until the visiting nurse mentioned a non-emergency transport was called. Regarding allegation, “Staff did not properly report incidents involving a resident”, LPA received information through interviews that R1 had a head injury on or about 3/27/23 where the responsible party was not notified in a timely manner and there was a R2 who fell on or about 9/28/22 where R1’s responsible party was asked to assist in lifting the resident. R2 is no longer living in the facility. Upon a research of files, LPA did not observe an LIC624 for either incident. Allegation is deemed SUBSTANTIATED Regarding allegation, “Resident sustained an unexplained injury while in care” LPA received information through interviews that R1 sustained bruises to the head and mouth between the dates of May 4th through May 20, 2024 from a fall. These bruises were brought to the attention of the responsible party by photos sent by staff who were not sure on how the bruises happened. Allegation is deemed SUBSTANTIATED Regarding allegation, “Staff unable to properly assist a resident while in care”, LPA obtained information that the Administrator was providing wound care at the facility. LPA observed a text message from Administrator to the family stating she was providing the wound treatment every day and dressing with calmoseptine. Due to this information from interviews and medical records review, Community Care Licensing (CCL) finds this allegation(s) to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client. The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49 is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining pressure injuries (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Licensee representative and a copy of this report was provided. LPA observed that on 5/21/24 a text from responsible party that indicated supplies will be delivered to the facility. LPA did not observe any written agreement stating the responsible party will or not provide supplies. Based on interviews, the verbal agreement was continued from June 2022 until R1 left the facility. Regarding allegation, “Staff intimidated a resident while in care” LPA received information through interviews that Administrator was observed to have a bad “tone” when speaking with R1. LPA obtained information through interviews that a visitor observed Administrator raise a hand at another resident on or about August or September 2023 and when questioned, the Administrator stated they were joking around. However, the resident is no longer residing in the facility. Regarding allegation, “Staff allowed a resident to be soiled while in care” LPA received information that although R1 did not have a foul body odor, upon arrival of visitation, R1’s clothing and gauze was soiled in the area of the wounds. During interviews, LPA obtained information that R1 did not have a body odor and the home was clean. LPA was unable to obtain a preponderance of evidence to substantiate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Licensee representative and a copy of this report was provided.