complaint·February 23, 2024

On 11/30/23, the Department received allegations that the facility did not seek timely medical attention and neglected care and supervision for a resident herein referred to as R1. R1 had an untreated wound which was not reported to licensing office. On 12/08/23, the Department conducted an initial investigation and interviewed staff (S1). S1 stated that R1 had an unwitnessed fall sustaining an injury to the left elbow with a superficial skin tear on 11/21/23. S1 stated that R1s fall was reported to responsible party (RP) and medical doctor (MD). S1 stated that R1’s wound was not serious, was cleaned and a band aid was applied. Since it was not serious, the facility did not report R1’s wound to licensing. On 11/27/23, R1’s responsible party moved R1 to another Residential Care Facility for the Elderly (RCFE). It was reported that during R1’s assessment the facility did not inform the prospective facility that R1 sustained a wound on elbow aside from other minor abrasion on his/her knee during an assessment. Based on review of Nurse’s notes dated 11/21/23, it was noted that R1 reported to the Wellness Nurse at 9AM that he/she fell during the night but does not remember how it happened. R1 sustained a left skin tear on left arm and some redness on left knee. R1s wound was cleaned and treated, and dressing applied. R1’s primary care physician (PCP) was notified on the same day [11/21/23] with a reply date of 11/24/23 which states, “can give Tylenol 500mg every 6 hours … and please wash skin tear clean and put band aid over.” On 11/28/2023, R1’s wound was reported to his/her PCP. PCP stated the facility staff did not describe the severity of the wound and how bad it was when he/she received a note from the facility On 11/21/23, the note states that R1 had a skin tear on left arm and some redness on the left knee. PCP prescribed R1 some antibiotics and will require the services of a home Health aide to come and assist with the wound care for R1 at his/her new placement. Based on record review such as R1’s physician’s report dated 5/23/23, R1 has diagnosis of neurocognitive disorder. Continue on LIC9099-C. Page 2 of 3. On 12/05/2023, LPA interviewed R1’s responsible party (referred to as RP). RP stated that on 11/21/23, he/she received a phone call from the facility staff to report that R1 had a fall and PCP was notified who prescribed medication for pain. RP stated there was no mention of R1’s sustaining a wound on the left elbow. RP became aware of R1’s wound on left elbow a day after R1 was admitted at another facility on 11/28/23 reported by the facility nurse, herein referred to as W1. RP stated that R1 moved out from the facility [Belmont Village] on 11/27/23. On 12/08/2023, the Department interviewed staff S1. S1 stated R1 did not complain about pain, per their procedure does not require staff to report to licensing if it is not critical or does not require any hospital visit/emergency. Based on interviews, and records reviewed, of incident submitted to the department, a report was not filed with licensing addressing R1s unusual incident (injury/fall) in November 2023. Based on records review of R1s progress note, no other reports was written after 11/21/2023 that the wound has been addressed. On 12/09/2023 the Department interviewed witness (W1) that R1 was assessed at Belmont Village prior to R1’s placement on 11/27/23. According to W1, it was mentioned by the wellness director or nurse [at Belmont] that R1 had a fall but no mention of an open wound on R1’s left elbow during assessment. W1 stated that R1’s wound discovered when R1’s moved in day on 11/27/23 which was covered by translucent tape over the wound with yellowish color appeared to be infected and wound dressing has not been changed. On 12/10/2023, an interview with W1 was conducted. W1 stated that the facility [Belmont] did not allow them to conduct skin assessment. Based on the Department’s findings, record reviews and interviews, there is sufficient evidence to prove that the allegation of neglect or lack of supervision, not seeking medical attention in a timely manner, and not reporting incident to licensing agency occurred. The preponderance of evidence gathered and analyzed indicated that the allegation is true, therefore, the allegations are substantiated . Deficiencies are cited based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with DRCS Jeeteeh Gigliotti and a copy of the report and appeals rights were provided. Page 3 of 3