complaint·January 3, 2025

Continued from LIC9099 The medication technician on duty provided facility staff with topical barrier cream to apply to R1 on 08/29/2024. Review of R1’s medication authorization record (MAR) showed that R1 had an ointment prescribed “as needed” for redness but the record did not indicate or show that an ointment was administered for R1 on 08/29/2024. Subsequently, there was no additional written documentation notated on R1’s MAR or progress notes to indicate that a change in skin condition was observed and that barrier cream was applied. Additional interviews also revealed that on 08/31/2024, another facility staff observed R1 to have a dark spot that was purple, brown, and leaking. This facility staff notified the medication technician on duty who stated they would notify management. Review of facility documents showed that on 09/01/2024, R1's nurse practitioner was faxed to notify them of the observation. Review of incident report dated 09/02/2024 stated that facility staff notified R1’s doctor of the wound on 09/01/2024 and that R1’s nurse practitioner called the facility on 09/02/2024 to request for R1 to be sent out to the hospital for an unstageable pressure wound on the coccyx area. Review of progress notes did not show any documentation or notification of a sore being observed for R1 by facility staff. Review of documentation also showed that seven staff were written up for failing to notice the wound on R1’s back. Based on interviews conducted, document review, and observations made, this allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An informal meeting will be scheduled at a later date between the Facility and the Department to be held at the Santa Rosa Regional Office.** Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.