complaint·July 1, 2024

LPA Moleski reviewed R1’s file and other medical records and observed no indication that R1 had ever suffered from bed sores or diaper rashes. None of the staff members interviewed reported having observed bed sores or diaper rashes on R1. Multiple staff interviews indicated that R1 is able to notify staff when toileting assistance is needed. LPA Moleski reviewed a fax dated 3/14/23 sent from facility staff to R1’s physician which described a fungal infection observed on R1’s anus. LPA Moleski interviewed the author of the fax, S5, who said that the infection resolved shortly after receiving cream prescribed by R1’s physician. S5 had not observed any bed sores or diaper rashes present on R1. The department has determined the following as it relates to the allegations that staff are not meeting a resident’s diapering needs, resulting in sores, and that staff made inappropriate comments toward a resident: Based on record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Barry. According to medical records, R1 was diagnosed with a fracture of the right kneecap and multiple fractures of the right side of the ribcage on 6/22/23. R1 underwent surgery on 6/24/23 to address this injury. R1 was sent to a rehabilitation center and returned to this facility on 7/15/23. On 7/18/23, R1’s home health nurse noted that a surgical wound on R1’s knee appeared to be infected, and instructed staff to send R1 to the hospital if the wound became redder in coloration. A fax was sent by facility staff to R1’s physician on the same day, stating that if the condition of the wound worsened, R1 would be sent out. According to facility notes, on 7/19/23, R1 fell, opening the pre-existing wound on their knee. A facility staff member cleaned and bandaged the wound, but R1 was not sent to the hospital until the next day, 7/20/23. No documentation exists that R1’s physician was notified when the fall occurred, and no documentation exists to show that R1’s responsible party (RP) was notified. In an interview, R1’s RP said that they were not notified after the incident. On 8/15/23, R1 suffered an unwitnessed fall. R1 was taken to the hospital and R1’s physician was notified. According to medical records, R1 was diagnosed with a fracture to the right kneecap on 9/4/23. An incident report dated 9/4/23 states that R1 fell onto their knees at the facility. R1 was taken to the hospital, and R1’s physician was notified. On 9/21/23, staff note that R1 had returned from their last hospital visit, and note that staff must make sure R1 does not fall again. On 10/29/23, R1 suffered an unwitnessed fall and was placed back into bed. On 10/30/23, R1 suffered an unwitnessed fall. R1’s physician was notified.¬¬ On 11/10/23, R1 suffered an unwitnessed fall. R1’s physician was notified. The Community Care Licensing Division (CCLD) received only two incident reports regarding any the above incidents: one, dated 8/15/23, and another, dated 9/4/23. Despite the number of falls suffered by R1 between 9/10/18 and 11/10/23, R1 did not receive an updated needs and services plan to address R1’s fall risk. R1’s most recent needs and services plan was dated 11/17/19 at the time this complaint investigation was opened. Interviews with current and former staff show that staff were aware R1 was a fall risk and that they were told to watch R1 closer, but were not asked to implement fall prevention measures, and no fall prevention plan was in place. [continued on 9099-C] LPA Moleski interviewed eight staff members (S1-S8) regarding R1’s hygiene care. S1 said a podiatrist trims residents’ toenails about once every two months. S3 was not sure who is responsible for trimming residents’ nails. S4 said R1’s RP cuts R1’s toenails, and also that a podiatrist is responsible for trimming residents’ toenails, but did not know how often the podiatrist comes. S5 said they had observed R1 with long, unkempt toenails twice, once around June 2023 and once around August 2023. S5 said that they raised concerns to management about the situation, but nothing was documented. S6 said that they were not sure who was responsible for trimming R1’s nails, and said they had observed R1’s nails long on one occasion, around fall 2023. S8 said they had seen many residents with long and unkempt nails, and said R1 was likely one of them. S8 said residents must be added to a special list to receive nail trimming services, and said the podiatrist will visit about once every two months. S8 said that R1’s hair was also sometimes dirty. R1’s RP said they had observed R1 with long and unkempt nails previously. The department has determined the following as it relates to the allegations that a resident fell sustaining fractures due to staff neglect, that staff did not seek medical attention for a resident, that staff did not notify a resident’s authorized representative of an incident, and that staff are not meeting a resident’s hygiene needs: Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87468.1(a)(2), 87465(g), 87211(a)(1)(B), and 87464(f)(4). An exit interview was held with Barry. Appeal rights and a copy of this report were left with Barry. This report was amended on 9/5/24 to include the following: A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Barry. Appeal rights, a copy of the civil penalty assessment, and a copy of this amended report were left with Barry.