complaint·March 25, 2022

of the investigation, staff and resident interviews were conducted both in person at the facility as well as over the telephone on the following dates: 08/24/2020, 08/25/2020, 12/14/2020, 12/17/2020, 05/26/2021, and 10/21/2021. The following was then determined: Regarding the allegation “Resident sustained bed sore while in care: Resident #1 (R1) moved into the facility on 06/01/2020. Resident’s paperwork filled out upon admission was reviewed and did not contain any indication of existing wounds upon admission to the facility. Interview with R1’s family member confirmed R1 had no pressure injuries prior to residing at the facility. Care notes reviewed did not indicate any wounds on R1’s body. The resident was admitted to hospice on 08/20/2020, at which point a Stage 2 wound was noted on R1’s coccyx, as well as skin tears on R1’s legs and both arms. Photographs of the wounds were provided to the LPA. Staff interviews revealed that R1’s pressure injuries were “real deep” and a “real bad wound.” Former administrator indicated they were unaware the resident had any wounds until R1 was admitted to hospice. Therefore, based on interview and record review, the allegation that “resident sustained bed sore while in care” is deemed SUBSTANTIATED at this time. Regarding the allegation “Resident not administered medication as prescribed: LPA reviewed R1’s medication administration record as well as care notes. Two times in June, on both the 26 th and 27 th , it was noted that R1 was unable to receive medications as prescribed, as the medications had not yet been refilled. Medication records reviewed indicated PRN acetaminophen was administered only one time in the month of August 2020 and PRN morphine was administered on 3 dates in August 2020. Interview with former Administrator revealed that the facility did not have a PRN authorization on file for R1. Therefore, based on interview and record review, the allegation that “resident not administered medication as prescribed” is deemed SUBSTANTIATED at this time. Regarding the allegation “Resident left in soiled clothing for extended period of time:" Review of R1’s Needs and Service Appraisal indicated that R1 requires assistance with ADLs including toileting assistance, dressing, bathing, and grooming. Interview revealed that on 08/24/2020, R1 was observed to have urine leaking from their pants and noted to be soiled in urine and feces. Staff interview indicated R1 had not been changed for some time, which resulted in the soiled clothing. The exact amount of time the resident was left in soiled clothing is unknown, however the feces was noted to be dried under the Report Continued on LIC 9099-C resident’s nails and on the resident’s clothing. Therefore, based on interview, the allegation “resident left in soiled clothing for extended period of time” is deemed SUBSTANTIATED at this time. Regarding the allegation “Facility staff not responding to resident’s call button:” Interview with a witness revealed that on 08/24/2020, the witness pressed the resident’s pendant while in R1’s room. The witness waited for over 30 minutes for a response and only received a response when using the telephone to call for assistance. R1’s call button was replaced that same day. However, the following day, on 08/25/2020, R1’s visitor pressed the pendant and again received no response for approximately 30 minutes. Staff interview revealed that according to facility policy, care staff should respond to a resident’s request for assistance within 2 alerts on the call system, which equates to 10 minutes or less. 6 (six) of 6 (six) residents interviewed all stated that call times vary, but all have had to wait upwards or 20 minutes to an hour for a response. SMARTCare records reviewed for a one-week period indicated a wait time or greater than 10 minutes for 175 calls during a one-week period. Additionally, during that same one-week period, there was no response to the call button at all 65 times. Therefore, based on record review and interview, the allegation “facility staff not responding to the resident’s call button” is deemed SUBSTANTIATED at this time. Regarding the allegation “Facility staff not safeguarding resident’s property:” Interviews conducted during the course of the investigation revealed that medical supplies were left in the resident’s room as of 08/22/2020. Those supplies were unable to be located as of 08/24/2020. Staff interview revealed that “caregivers take patient supplies for use on other patients” and Administrator added that “things should not be left in patients’ rooms because they have been found to go missing.” In addition to medical supplies missing, R1's family left an electronic item for R1 which was also unable to be located. Based on interview, the allegation that “facility staff not safeguarding resident’s property” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D.) The Sales Director was informed that civil penalties may be assessed at a later date based on Health and Safety Code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report was issued via email.