complaint·August 29, 2023

R1’s family denied that R1 had a history of skin breakdown. Relevant party reported that R1 had two small pressure wounds to their buttocks which had healed when they were first in care at Oakmont of Fair Oaks. R1’s Individualized Service Plans (ISPs) dated 10/22/2022, 11/22/2022, and 2/26/2023 noted that R1 had no skin breakdown. The ISPs note that R1 did not require status checks. R1 is noted as being full assist and requiring one person assist for transfers. Staff reported R1 was a two person assist in part due to their aggressive behaviors. There is no notation in R1’s ISPs that R1 required care specific to prevention of pressure wounds such as repositioning, cushions, pillows, heel floats, etc. Staff were inconsistent as to whether or not there was direction to rotate, reposition, or use props and/or pillows for R1. Staff consistently reported that R1 was physically combative, verbally aggressive, and resistive to care. R1 was sent to the hospital on 2/24/2023 for the wound to their right heel. Hospital records note R1 had the following wounds: unstageable pressure wound to left ankle, wound to left leg (not pressure wound), unstageable pressure wound to left heel, and unstageable pressure wound to right medial foot. Multiple staff interviewed reported that R1 had a “black” wound to their heel from the time they were first admitted to Oakmont of Fair Oaks (in 10/2022). Multiple staff reported telling the Memory Care Director (MCD), Belinda Prunty, and the facility nurse, Laurel Sanders, LVN, Health Services Director (HSD) about the wound. HSD reported seeing the wound and contacting MCD to initiate home health care. HSD denied knowing about the wound previously. HSD was not sure of the time frames between seeing the wound, and when home health care came to the facility. MCD reported that R1 had the wound to their heel upon admission to the facility, and MCD reported telling HSD about the wound. The home health nurse (HHN) who came to see R1 on 2/24/2023 described the wound to R1’s heel as “significant.” HHN felt the wound had been present for at least weeks and had been developing for some time based on the dryness of the wound, and the necrotic tissue. Oakmont of Fair Oaks did not have any documentation of routine skin check and shower sheets, and they only had case notes for R1 for the month of 10/2022. Multiple relevant parties reported to the Department varying accounts of medication mismanagement by facility staff. LPA reviewed an internal document indicating that, on 1/1/2023 during a medication audit, it was found that a medication that was supposed to be given to a resident was not in the medication bin. ** Report continued on 9099-C ** Through more investigation, it was determined that the medication was reviewed and approved by MCD and listed to be “injected” even though the facility does not have injectable medication that they can administer. It was documented that MCD did not check to see if medication was at the facility and records indicated that medication had been marked as “given” by other med-techs. During a visit conducted on 5/17/2023, LPAs Michael Hood and Angela Hood conducted a medication count for residents R2 and R3, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPAs observed three (3) medications for R2 that were off count in relation to what was documented. All three medications that were off count were over the amount documented. Facility was able to account for 1 day (4/29/2023) in which R2 was out of the facility, but no other refusals were documented that could account for the amount over what was documented. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation. Multiple relevant parties reported to the Department that facility staff do not provide assistance with incontinence care. Interview with resident (R4) indicated that they do not receive assistance with incontinence care due to being required to use a shower chair. Interview with ED indicated that the facility required R4 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident. ED stated that R4 personally made the order for the shower chair and shower chair was not provided by the facility. ED stated that it took 30 days to obtain the first shower chair, in which resident refused to use due to being uncomfortable, and another 30 days to obtain a second shower chair that the resident was able to use. ED stated that R4 was originally admitted with the use of a hoyer lift, but R4 refused to use hoyer lift after admission due to being uncomfortable for resident. Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 for R4 indicated that resident required a two-person assist with the use of a mechanical lift. Resident Assessment dated 4/13/2023 for R4 indicated that R4 “requires two-person physical assistance with transfers.” ** Report continued on 9099-C ** LPA reviewed R4's Physician's Report for RCFE LIC 602A dated 8/8/2022 and observed R4 was in need of assistance with toileting. LPA reviewed R4's Preplacement Appraisal Information (LIC 603) and observed R4 is "unable to transfer unassisted" regarding toileting. LPA reviewed R4's Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 indicating that R4 "requires stand-by assistance for toileting," and 4/13/2023 indicating that R4 "requires hands-on assistance with incontinence; gathering incontinence supplies, hygiene, and/or changing linen." LPA reviewed the facility’s shift notes from April 2023 to August 2023 and Staff Assignments by Month by Unit for R4 from May 2023 to August 2023. LPA observed only the morning of 6/1/2023 documented as having R4 receiving incontinence care for the month of June 2023. All other entries for June 2023 were blank and not documented as care given. ED was unable to provide any additional documentation regarding R4's incontinence care. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation. Based on interviews conducted and records reviewed by the Department, as well as a medication count, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. As a result of the resident’s serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 for the date of 8/29/2023 is assessed for a violation that the department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents. The Department obtained medical records for resident (R1). The Department also obtained Unusual Incident Reports (SIRs) regarding falls for R1. A review of the documents obtained identified two (2) incidents in which R1 was sent to the hospital for falls. On 11/19/2022, R1 was sent to the hospital due to an unwitnessed fall. R1 denied hitting their head or having loss of consciousness. CT scan of R1 ruled out any injuries and was negative for any traumatic injuries. On 1/3/2023, R1 was sent to the hospital after an unwitnessed fall. CT scan of R1 did not show evidence of intracranial trauma and chest x-ray was unremarkable. During both incidents, R1 returned to the facility in stable condition. SIR regarding incident on 11/19/2023 indicated R1 was placed under observation for the following 72 hours. Interviews conducted with staff members S1, S2, S3, S8, S9, S10, and S11 indicated that they haven't witnessed any residents sustain serious injuries due to falls or not receive assistance from staff after falling. Interviews with S8, S9, and S10 indicated that they worked with R1 and did not witness R1 sustain any injuries due to falling. Interviews with residents R4, R5, R6, and R7 indicated that they have not experienced or witnessed any residents sustaining falls due to lack of supervision. The Department determines that there is insufficient evidence to suggest that lack of supervision resulted in resident sustaining falls. LPA observed a Client/Resident Personal Property and Valuables LIC 621 on file at the facility for R1. No items were listed on LIC 621 for R1. LPA observed an Optional Inventory of Personal Property for R1 signed by R1’s responsible party and dated 10/5/2022 indicating that R1 and/or their responsibly party did not wish to inventory personal property. LPA observed records for residents R4, R8, R9, and R10 and observed the same documentation indicated the individuals did not wish to inventory personal property. No interviews conducted with staff identified any instances of theft. Staff interviews identified proper reporting in the case of found property to return property to resident. Interviews with resident R4, R5, R6, and R7 indicated that they have never experienced or witnessed any incidents of lost or stolen property. Resident (R1’s) Pre-placement appraisal LIC 603 dated 10/5/2022 indicates that R1 does not need help with eating, adaptive devices or assistance from another person. Resident Assessment for R1 dated 10/18/2022 indicates that R1 requires meal-time reminders. R1’s Individualized Service Plans (ISPs) dated 10/22/2022 and 11/22/2022 indicates that R1 requires meal-time reminders and maintains independence in dining. ** Report continued on 9099-C ** Resident care notes from 10/23/2022 to 10/31/2022 document resident’s eating habits. R1’s ISP dated 2/26/2023 indicates that R1 resists eating and has difficulty in maintaining adequate nutrition, with complete assistance and hands-on feeding required for eating. Interviews conducted with staff members S8, S9, and S10 indicated that they worked directly with R1 and monitored their food intake. Interviews with staff members S4 and S7 indicated that all residents in need of feeding assistance are provided services. Multiple relevant parties reported to the Department that the facility was either unclean or in disrepair on separate occasions. Interviews conducted with staff members S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, and S11 as well as residents R4, R5, R6, and R7 indicated that they have no issues with housekeeping or have never witnessed anywhere in the facility to be unclean or in disrepair. During visits conducted at the facility, LPA did not observe the facility or any apartments to be unclean or in disrepair. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.