Complaint·July 11, 2024

Page 2 of 2. Based on interview with family member (FM1), staff S2 called FM1 on 5/18/2024 at approximately 9:00am to inform them about noticing blood during R1's incontinence care. Based on an interview with family member (FM2), staff S2 called FM1 on 5/18/2023 at 9:18am to request home health nurse to observe the wound, referring to the blister. On 8/16/2023, the Department interviewed Licensee (LIC), who stated staff S1 called LIC at approximately 5:30am regarding R1's blister/wound and S1 informed S2 during shift change. LIC stated at approximately 8:00am, R1's responsible party was informed. LIC stated from 5/18/2023 - 5/26/2023 she was communicating with R1's responsible party via phone call to schedule an appointment with R1's primary care physician and request for home health nurse to visit R1 at the facility. On 8/16/2023, the Department interviewed 3 staff (S1-S3), 3 out of 3 staff stated the facility staff informed R1's responsible party regarding R1's blister/wound the morning of 5/18/2023 via telephone call and requested a visit from the home health nurse. The Department has completed the investigation of the above allegation. Based on interviews conducted and record review, the Department has found that the above allegation were UNFOUNDED, meaning the allegations were false, could not have happened and/or without a reasonable basis. No deficiencies were cited from California Code of Regulations, Title 22 during today's visit. This report was reviewed with the Licensee, Dominica Olivia and a copy of the report was provided. Page 2 of 2. Based on interview with family member (FM1), R1 was taken to the hospital on 5/26/2024 after an appointment with R1's primary care doctor. O'Conner Hospital assessed R1's wound on coccyx as a stage 4 pressure injury. Based on interview with family member (FM2), on 5/18/2024, home health nurse visit R1 at the facility and the wound near the tailbone was measured as a stage 2 wound. On 5/22/2023, FM1 spoke with home health nurse and stated R1's wound was stage 2 and the wound would continue to be treated with Tera Honey and bandaged. On 5/23/2023, the condition of the wound changed where the wound was described as "yellow with pus discharge". On 5/24/2023, the home health Physical Therapist (PT) observed the wound was growing bigger and now was a "deep hole with oozing pus". On 5/26/2023, FM1 transported R1 to R1's doctor's appointment where R1's primary care physician advised R1 to be taken to the Emergency Room immediately. On 5/27/2024, after R1 was diagnosed with stage 4 pressure injury, R1 underwent surgery for the wound. Based on review of R1's progress notes, On 5/23/2023, staff noticed R1's wound changed condition and on 5/26/2023, R1 received medication attention and wound was assessed as a stage 4 pressure injury. On 11/16/2023, the Department conducted an interview with the Licensee (LIC). LIC stated the facility can only keep a resident with a stage 2 wound and if the wound worsens to anything above a stage 2, the resident will need to be transported to the hospital for an evaluation. LIC stated R1 was not under Hospice services. The Department has completed the investigation of the above allegation. Based on interviews and record review, the preponderance of evidence standard as been met therefore the above allegation is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today's visit, see LIC 9099-D. This report was reviewed with Licensee, Dominica Olivia and a copy of the report was provided. Appeal Rights were provided.