Complaint·March 14, 2023

Licensing Program Analyst (LPA), Jason Lund conducted an unannounced visit on 3/29/2023 to amend the complaint and met with Administrator Mary Keaton and explained the reason for the visit. The wound opened up and began to drain that night. On November 16, 2022 R1 was in a lot of pain and did not eat breakfast. On November 17th, 2022, R1 was sent to the hospital after R1’s wound was draining and had a foul odor. The hospital diagnosed R1 with a stage 4 wound, underwent debridement and suffered from sepsis. R1 was discharged from the hospital on hospice and passed away on December 1, 2022. The facility staff did not provide an explanation of why R1 was not provided timely medical assistance. Facility staff neglected Resident’s resulting in injury- Staff were aware that Resident (R1) had a wound and communicated with R1’s Physician regarding the wound; however, the wound continued to progress. As the wound worsen, R1 showed other symptoms such as not eating, no signs of progress and R1 continued to be lethargic which was a considered a change of condition. Staff failed to notice those changes and failed to seek medical attention resulting in R1 being diagnosed with stage #4 wound and sepsis. R1 was discharged from hospital on hospice and passed away on December 1, 2022. As a result of this investigation, LPA Lund finds allegations to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations. Per California Code of Regulations, Title 22, the following deficiencies, and immediate civil penalty have been issued. The circumstances of this complaint are being evaluated for enhanced civil penalties. The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of the resident sustaining a pressure wound (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty. Exit Interview give and report left.