Complaint·August 2, 2021

On 08/26/2020 and 09/03/2020 a total of three family members were interviewed. 3 out of 3 family members stated they did not observe the resident with any pressure injuries or open wounds, and staff reposition the resident. All family members stated they are in communication with the facility staff regarding the resident’s condition. On 06/24/2020 LPA toured the facility and did not observe any open wounds or pressure injuries on the residents. Medical records dated 04/18/2020-05/13/2020 indicated R1’s skin was warm, dry, and no rashes. R1 had wounds and wound care was provided. Medical records did not indicate R1 had any pressure injuries on the body. Physician’s report indicated R1 had a history of skin breakdown and did not note any pressure injuries on the body. R1’s care plan indicated that the facility notified R1 primary physician on 04/27/2020 and responsible party on 04/23/2020, 04/18/2020, and 05/09/2020 regarding R1’s condition. This Department has investigated the above allegations, and based on interviews, records review, and observation the Department has determined that the allegations were Unsubstantiated , meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. This report was review with Jennifer Flores Administrator and a copy of this report provided. Between 06/24/2020-07/09/2020 a total of five residents were interviewed. 4 out of 5 residents stated staff assist them with brushing their teeth or they brush their teeth independently. Four residents stated they are offered liquids throughout the day for hydration. One resident was not able to answer questions regarding assistance with teeth brushing and liquids being offered. S1 stated R1’s Physician’s Visit Report dated 22/8/2020 was reviewed and S1 notified the responsible party that the facility cannot assist with glucose testing. R1 was not able to perform own glucose testing. Doctor’s orders dated 2/28/2020 included blood glucose testing daily. Testing was not completed per doctor’s orders. Medical records indicated on 04/18/2020 and 05/09/2020 R1 was taken to the hospital and lab work indicated elevated glucose levels. Medical records also indicated on 05/09/2020 R1 hospital records noted R1 admitted at 3:11pm for an altered mental status. Based on interviews and review of documents, the preponderance of evidences standard has been met, therefore the above allegations were found to be SUBSTANTIATED . California Code of Regulations, (Title 22), are being cited on the attached LIC9099D. Failure to correct the deficiencies may result in civil penalties. This report was reviewed with Jennifer Flores Administrator, and a copy of this report and appeal rights provided.