complaint·November 29, 2022

On 08/12/2022, from 9:25am to 11:30am, LPA Camara conducted the initial 10-day complaint visit. The LPA met with administrator Halina Garbacz and assistant administrator Bryant Barron and explained the reason for the visit. During the visit, LPA conducted a brief facility tour at 9:30am and reviewed and obtained pertinent documents starting at approximately 9:55am. The administrator was notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) for further investigation. Investigator Zertuche conducted an interview on 08/17/2022, at approximately 4:00pm, with a Hospice staff; on 09/01/2022, at approximately 12:00pm, with a Hospice nurse; on 09/02/2022, from approximately 10:00am to 1:30pm, with facility administrator, a facility staff, facility residents, and R1’s resident representative; an attempt to conduct an interview with Staff #1 (S1) was made at approximately 1:00pm, however, S1 did not return the phone call. On 09/20/2022, at approximately 12:30pm, Investigator Zertuche contacted the Ventura County Sheriff’s Department and was informed that there was no report on file for this case; at approximately 1:00pm, the investigator contacted the Long Term Care Ombudsman (LTCO) and was informed that they received a report of the incident. Additionally, Investigator Zertuche reviewed copies of R1’s Hospice records. A review of the hospice records revealed R1 was on hospice care and diagnosed with end-stage dementia and Ischemic Cardiovascular disease. R1 was bedridden and required assistance with most activities of daily living. On 08/08/2022, at approximately 8:00am, the hospice aide found R1 covered in ants and R1’s adult diaper completely saturated along with a new wound on the right upper shoulder. The hospice aide contacted the hospice agency and informed the nurse of the findings. The hospice nurse visited the facility later that day at approximately 4:00pm. By then, R1 was clean, and the bedding and room were also clean. The nurse observed an open wound to the top of the shoulder which measured at stage III. Since R1 was declining and on hospice, R1 was bed bound, weak, did not eat well and skin was thin which required regular repositioning. However, it appeared as if R1 was not being repositioned or checked on based on R1’s diaper being soiled, a new injury forming, and ants found all over R1’s body. There were no logs documenting R1’s care. No photos were taken and R1 was not sent to the doctor since R1 was receiving hospice care. There were no issues documented prior to this date and subsequent visits showed R1 and R1’s room were clean with no concerns . (continued on 9099-C) The administrator stated she was the only staff member present during the overnight hours. She stated she is the only person who works overnight and does not sleep. She stated she sleeps in the afternoons when other staff are present. On 08/08/2022, one staff member arrived at 7:30am, which was shortly before the hospice aide arrived. The administrator stated she checks and repositions the residents every two hours. However, she reported changing R1’s diaper at 4:30am but not again until the hospice aide arrived around 8:00am. The administrator admitted to not knowing about the new wound on R1’s shoulder until hospice informed her. Staff #2 (S2) stated they were not working on 08/08/2022. S2 stated they change R1’s diaper when it is wet, usually every few hours, but does not reposition R1 since it is difficult to get R1 out of the bed. S2 stated prior to leaving their shift on Sunday evening, 08/07/2022, they did not notice anything unusual on R1, including ants or any new injuries. On the allegation - Neglect/Lack of Supervision – Resident #1 (R1) wounds were infested with ants – The administrator stated she was the only person working the overnight shift and reported she last checked on R1 at 4:30am the day of the incident on 08/08/2022. The administrator stated she repositioned R1 every two hours, but the next check on R1 was by the hospice aide at approximately 8:00am. Additionally, the administrator had no knowledge of the new wound on R1’s shoulder, which was an open wound at stage III, according to the hospice nurse. Furthermore, when the hospice aide arrived the morning of the incident, R1 was covered in ants throughout R1’s body and R1’s diaper was soiled. The hospice nurse, a credible witness, determined there was neglect in this case as it did not appear as if R1 was checked on for quite some time for R1’s body to be covered with ants and diaper soiled. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation Neglect/Lack of Supervision – Resident #1 (R1) wounds were infested with ants, is Substantiated at this time. (continued on 9099-C) On the allegation - Neglect/Lack of Supervision – Staff members failed to reposition Resident #1 (R1) - The administrator stated she was the only person working the overnight shift and reported she last checked on R1 at 4:30am the day of the incident 08/08/2022. The administrator stated she repositioned R1 every two hours, but the next check on R1 was by the hospice aide at approximately 8:00am. Additionally, the administrator had no knowledge of the new wound on R1’s shoulder, which was an open wound at stage III, according to the hospice nurse. Furthermore, when the hospice aide arrived the morning of the incident, R1 was covered in ants throughout R1’s body and R1’s diaper was soiled. The hospice nurse, a credible witness, determined there was neglect in this case as it did not appear as if R1 was being repositioned, as was needed. S2 also admitted they do not reposition R1. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation Neglect/Lack of Supervision – Staff members failed to reposition Resident #1 (R1), is Substantiated at this time. A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.