Complaint·August 5, 2025

LPA review of hospital records for R1 during their stay from 1/6/2025 to 1/9/2025 revealed R1 was admitted to the hospital due to weakness and had discharge diagnoses of malaise and fatigue, diarrhea, anasarca, anemia of chronic disease, BPH with urinary obstruction, essential hypertension, obesity, and type 2 diabetes mellitus. Hospital records indicate a wound was noted by hospital staff on R1’s buttock on 1/6/2025 at 2:21pm. Hospital discharge notes state resident discharged to facility on service with Home Health. Review of Central Coast Home Health (CCHH) notes for R1 revealed the first nurse visit for R1 at the facility was on 1/14/2025 and at this visit the nurse noted “pressure ulcer wound location: right buttock…”. No other wounds were noted. The next nurse visit was on 1/17/2025 and the nurse noted three wounds; Wound 1 was a stage one pressure injury located on R1’s coccyx with a size of length: 0cm, width: 0cm, depth: 0cm, status of closed - present on admission, 100% red/pink and no wound pain. Wound 2 was a stage 2 pressure injury located on R1’s left heel, with status of closed and surrounding tissue intact, onset date 01/15/2025. Wound 3 was a lateral left heel blister, with a status of closed, onset date of 01/16/2025. LPA staff interviews revealed they noticed a blister on R1's left heel when they showered them on 1/10/2025 and reported it to R1's family. Record review of R1’s facility file reveal no note of skin issues or pressure injuries. Staff stated they would encourage R1 to recline their feet up and would offer a pillow to float their feet, but R1 often refused or would remove the pillow. P1 purchased padded foot booties for R1’s feet, staff would put them on, but R1 did not always tolerate them. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff neglect resulted in a resident's change in medical condition. It was alleged while in the facilities care, R1 was transported to the Emergency Room for various issues caused by the Care Facility that they never had at home. LPA record review revealed throughout R1’s stay at the facility from 1/9/2025 to 2/28/2025 R1 was sent to the emergency room on two occasions, 1/21/2025 and 2/28/2025. Record review and interviews revealed on 1/21/2025 staff and CCHH nurse noted blood in R1’s urine. Facility staff called 911 and R1 was transported to Sierra Vista Regional Medical Center around 1:27pm. Hospital discharge notes indicate resident was discharged on the same day around 8:54pm and returned to the facility with the discharge diagnosis of hematuria. (Continued on 9099-C) LPA record review and interviews revealed on 2/28/2025 Staff 1(S1) assisted R1 with their morning routine. S1 stated after transferring R1 to the recliner in their room R1 was trembling, sweating, and responsive. S1 stated they suspected R1’s blood sugar was too high or too low, S1 called R1’s family member (P1) regarding the symptoms. In interview with P1, P1 suggested S1 give R1 apple juice to see if it helps and call 911 if they think it’s needed. R1 refused the apple juice and S1 called 911 around 8:00am. LPA record review and staff interviews revealed R1 did not have a physician order to test blood glucose levels and took metformin twice daily to manage their diabetes. LPA record review of R1’s hospital records revealed R1 was discharged from the hospital to a skilled nursing facility on 3/5/2025 and discharge diagnoses of hypoglycemia, new onset atrial fibrillation, and altered mental status. R1 did not return to the facility after this hospitalization. P1 stated they couldn’t return R1 to the facility after the issues R1 had. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff did not meet a resident's showering needs while in care. It was alleged R1 was only receiving bed baths since they moved in because the facility does not have an American’s with Disabilities Act (ADA) shower room. R1 had a shower chair on wheels and shower bench, but neither of these worked with the facility showers. LPA noted the facility is not required to have ADA showers/baths per Title 22 regulations. LPA noted the shared bathroom has a walk-in shower with a 4.5 inch ledge to step over to get in. Text messages between the Administrator and P1 reveal R1 had a shower on 1/10/2025. LPA interviews with staff revealed if R1 wanted a shower they would assist them to do so, but R1 often refused showers stating they were afraid of falling. Staff stated when R1 was willing they would place towels down on the bathroom floor, place a shower chair on the towels, R1 would sit in the chair and staff used the handheld shower head to shower R1. When R1 refused showers, staff would offer bed baths using warm water, soap and towels to care for R1 in bed. Staff stated R1’s family did not tour the facility prior to admission. LPA interview with P1 confirmed they did not tour the facility before as the hospital was attempting to quickly discharge R1 and P1 used a placement agency to find a facility for R1. Based on the information obtained, the allegation is deemed unsubstantiated at this time. (Continued on 9099-C) On the allegations: Staff did not meet a resident's diabetic needs and staff mishandled a resident's medications. It was alleged facility staff did not provide R1 their meals and medications timely causing frequent low blood sugar not noticed by staff, and R1 allegedly lost weight. LPA record review and staff interviews revealed R1 did not have a physician order to test blood glucose levels and took metformin twice daily to manage their diabetes. LPA reviewed medication administration record which showed medication was given as prescribed and staff stated R1 knew their medications and regularly asked for them on time. Record review of R1’s LIC602 noted R1 requires a diabetic diet. Staff stated P1 would bring R1 food to eat based on their diet needs. P1 also wrote down meal preferences for the facility to follow for R1 and R1 knew they were diabetic and would not request anything outside of these preferences. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff are not properly trained. It was alleged the facility has too many high need residents and unqualified people managing them and not trained well. Many don’t seem trained at all. LPA record review of staff training for the years of 2024 and 2025 revealed 3 of 3 staff completed required training per Title 22 and California Health and Safety Code for staff at this facility type. LPA resident interviews revealed they receive the care they need, staff offer them showers or bed baths, and additional care. Based on the information obtained, the allegation is deemed unsubstantiated at this time. On the allegation: Staff did not meet a resident's mobility needs while in care. It was alleged R1 sustained pressure sores from facility staff seating R1 in a side chair next to the bed with their feet pressing on the floor and not moving him all day, a wheelchair was brought for R1 and staff never put R1 in it. LPA staff interviews revealed R1 requested to be in bed or the recliner in his room. Staff attempted to get R1 to spend time in the living room on multiple occasions but R1 often refused or would spend a short period of time outside his room and request to return to his room. Based on the information obtained, the allegation is deemed unsubstantiated at this time. During the course of the investigation LPA noted a violation and cited on a separate case management report. Exit interview conducted, report signed and provided.