complaint·January 13, 2022

Documents show on February 10, 2021, that treatment notation of pressure injury medical professionals to evaluate and treat coccyx stage 4 pressure injury with surrounding DTI. On February 15, 2021, records show that R1 continued with the 2cm x 2cm stage 4 pressure injury and that R1 was receiving wound care visits three times a week. Interviews revealed that R1’s pressure injury changed to a stage 4 within days. Interview with an outside source revealed they had no concerns or issues were noted with the care that was provided to R1 by the facility caregiving staff. The outside source and caregiving staff increased the frequency of checks on R1 and to monitor their vitals. Care staff rotated R1 every two to three hours and whenever R1 had to be changed for toileting. Based on the evidence obtained from the investigation, the above-mentioned allegation is unsubstantiated. It was alleged that the resident was financially abused while in care. Evidence obtained from resident and staff interviews revealed that (R1) was not in charge of their finances and did not have access to their money. R1 did not maintain money at the facility and staff interviews revealed that R1 did not hand out money or loan money to anyone. Interviews revealed R1 was not observed giving money to staff. Based on the evidence obtained from the investigation, the above-mentioned allegation is unsubstantiated. An exit interview was conducted with Ashley Marcellus, Administrator . A copy of this report, and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents. Conflicting information was received during other interviews, staff were not aware of the furniture being discarded, and staff did not know what happened to the furniture. Interviews with an eye witnessed revealed that during R1’s move to assisted living, the furniture was moved outside and seen with the trash. Documents reviewed during the investigation produced a letter from the prior administrator offering compensation for the furniture and other miscellaneous items to the responsible party. Based on the evidence obtained from the investigation, the above-mentioned allegation is substantiated. The deficiency is cited in accordance with California Code of Regulations, Title 22, and are recorded on the attached 9099-D (Deficiency) Page. An exit interview was conducted with Ashley Marcellus, Administrator. A copy of this report, the LIC 9099D, and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.