complaint·October 11, 2024

[CONTINUED FROM LIC 9099] At the time of the complaint allegation, R1 was being followed by a visiting nurse practitioner (NP), who operated as an extension of R1’s primary care physician (PCP), to help address R1’s health issues as they developed. Care records and interviews aligned to show that R1 was memory-impaired, wheelchair-bound, took blood-thinner medication, had very fragile skin, had a history of being prone to bruising and skin tears, and required staff assistance with bathing, among other tasks. Interviews of multiple staff and outside sources corroborated that during mid-July 2024, R1 sustained a skin tear on their lower left leg. CCLD obtained a photograph of the skin tear, showing that at one point, the open area of skin was around 3 inches long by 2 inches wide. In their interview, Staff #1 (S1) confirmed that while cleaning R1’s lower left leg with a loofah during a shower, they scrubbed too hard and accidentally caused the skin tear. S1 admitted that they did not inform either R1’s NP or PCP, or facility management. S1 also admitted they did not inform the RP until eight (8) days after it had occurred, and only after the RP had visited the facility and confronted S1 with questions about the skin tear. Interviews of the PCP and NP confirmed that facility staff did not notify them of R1’s injury. Interviews of Staff #2, Staff #3, and outside sources confirmed S1’s account, and that Licensee’s staff did not notify RP of the injury until over a week later. LPA reviewed the CCLD San Diego Regional Office’s files, finding that Licensee did not submit a written incident report regarding R1 sustaining a skin tear on their lower left leg (which was required to be done within seven days of incident occurrence). By the start of CCLD’s investigation, the skin in the affected had already scabbed over and healed, yet 2 of 2 facility Licensees/managers and 2 of 5 caregivers (who directly cared for R1) interviewed were still unaware of said earlier skin tear on R1’s leg. There was also no written documentation of this skin tear on R1’s lower left leg in the facility’s records, as was required. Interviews of facility Licensees/managers, caregivers, and outside sources aligned to show: During the time frame of the complaint, R1 and R2 were the only two residents in care at Oceanside Elderly Care Home 448. On a day in late July 2024, Licensee moved R1 and R2 to new bedrooms at Oceanside Elderly Care Home 452 (a separate CCLD-licensed care facility), to consolidate operations and reduce operating costs. Licensee did not prior notify CCLD of these transfers, or the fact that Oceanside Elderly Care Home 448 would become dormant. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] R1 and R2, per their latest physician’s reports and care records, both suffered from memory loss. LPA interviewed each and found neither could provide informed consent to transferring facilities. Manager and outside source interviews further showed that Licensee did not notify R1’s responsible person about R1’s moving, either before, during, or after the transfer. R1’s responsible person did not consent to the transfer. Per manager interviews, Licensee did contact and receive permission from R2’s responsible person to transfer R2. LPA attempted multiple times to interview R2’s responsible person to confirm this but was unsuccessful in reaching them. Based on records and interviews, a preponderance of evidence exists to show: After R1 sustained a skin tear on their lower left leg, Licensee did not notify R1’s healthcare providers of the injury, Licensee did not meet other reporting requirements, and Licensee involuntary transferred R1. These three (3) allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 9099-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099] Per review of CCLD’s Guardian and Licensing Information System (LIS) databases, during the time frame of the complaint allegation, both S4 and S5, as well as all other current facility staff, were each fingerprinted and possessed active background clearances to work. Interviews of Licensees/managers and facility staff reiterated the same. Based on record review and interviews, the allegation that Licensee’s staff did not have current background / criminal-record clearances is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was issued for it. An exit interview was conducted with Dr. Rahman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.