complaint·July 26, 2023

Continued from LIC-9099 Additionally, it was alleged that on May 11, 2023, R2 arrived at their medical appointment with an injury that was not previously reported to medical provider. Medical records collected for R2 revealed that R2 arrived at medical appointment with left eye swelling and bruising, medical notes state facility was contacted and facility staff communicated awareness of injury but was unsure how injury occurred. Interview with facility staff revealed that R2 had a bruise on left side of face as of May 6, 2023. Interviews with staff also established that it was unsure if facility had reported change in condition to medical provider. Interview with outside source revealed that a healing bruise was seen on R2 as of May 8, 2023. Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Wellness Coordinator Jenna Purnell, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. Continued from LIC9099-A Records also revealed that as of May 17, 2023, same stage 2 pressure injury to left ischial tuberosity had healed. Additional records revealed that on May 17, 2023, another stage 2 pressure injury to the coccyx was found. Records also established that as of May 24, 2023, stage 2 pressure injury to coccyx had healed. Interviews also revealed that R1 is bathed two times a week with skin checks and no skin issues had been noted by staff. It was also alleged that R1 was found to have multiple minor injuries throughout their body due to neglect. Medical records collected revealed that R1 was found to have fluid filled blister on the palm of the left hand; a shallow linear light pink abrasion to the right forearm and a light blue- green bruise to inside of left knee. Interview with Administrator revealed that R1 tends to scratch self with nails, leaving small scratches on their arm. Administrator also revealed that blisters would commonly appear on R1’s hands and they had been reported to physician. Interview with staff revealed that there was no known cause to R1’s bruise to the inside of the knee. Interview with outside source revealed no issues with R1’s care at facility. Lastly, it was alleged that R1 was restrained to wheelchair by facility staff. Interviews with staff present on the date of the incident revealed that no staff used wheelchair seatbelt on R1. During investigation, there was no other corroborating evidence to show R1 was restrained to wheelchair by facility staff. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Wellness Coordinator Jenna Purnell, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.