Complaint·March 30, 2022

toured the facility with Administrator and requested pertinent staff and resident documents. On 11/03/2020, 11/04/2020 and 11/05/2020, Investigator Ferris conducted telephone interviews with pertinent parties. On 11/13/2020, Investigator Ferris conducted in person staff interviews at the facility. Investigator Ferris then reviewed R1’s medical records and other pertinent documentation obtained from the facility. The following was concluded: Documents reviewed revealed that R1 was admitted to the facility on 02/06/2020. At that time, although R1’s physician’s report indicated “history of skin breakdown” no open wounds were noted upon admission. In fact, Home Health report dated 02/11/2020, indicated “blanchable redness on bilateral buttocks. Caregiver, (family member), Assisted Living LVN all notified.” Instruction was provided to the caregivers on changing R1’s position regularly, managing incontinence timely, and keeping the skin clean and dry. By 02/14/2020, Home Health records indicate “patient observed with dressing on sacrum area. When dressing removed, observed open wound on sacrum…caregiver, (family member,) Assisted Living LVN all notified. Caregiver stated she had the nurse look at the area this am and he applied the dressing.” By 02/18/2020, the wound was noted “much larger and deteriorating.” On 02/20/2020, the wound was recorded as a Pressure Ulcer Stage IV. Interviews conducted during the course of the investigation revealed that facility staff were aware R1 had developed a “bad pressure injury” prior to being placed on hospice. Record review revealed that R1 was placed on hospice effective 02/21/2020, although the pressure injury was noted a week earlier on 02/14/2020. Based on all information obtained, the above allegation “due to lack of care and supervision, resident developed a pressure injury while in care” is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The Senior Executive Director 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 and civil penalty issued. A copy of this report and appeal rights were issued via email. 11/04/2020 and 11/05/2020, Investigator Ferris conducted telephone interviews with pertinent parties. On 11/13/2020, Investigator Ferris conducted in person staff interviews at the facility. Investigator Ferris then reviewed R2’s medical records and other pertinent documentation obtained from the facility. The following was concluded: Documents reviewed revealed that R2’s care plan contained service plan for cardiac alerts to be performed by care staff and included information on signs and symptoms to observe R2 for and to alert LVN/Med Aide if observed. Additionally, R2’s care plan indicated presence of a pacemaker alert since 01/18/2019. On 10/09/2020, a faxed copy of R2’s death report was received in the Woodland Hills Regional Office. Death report indicated on 09/19/2020, R2 was admitted to the hospital due to shortness of breath and chest pain. R2 returned to the facility on 09/30/2020. Record review revealed R2’s physician’s report was updated upon discharge from the hospital on 09/30/2020, indicated R2 had a diagnosis of end stage heart disease. R2 was then admitted to hospice on 10/01/2020 with a diagnosis of Congestive Heart Failure/Atrial Fibrillation. R2 had a Do Not Resuscitate (DNR) order in place as of 10/01/2020. R2’s death report indicated on 10/02/2020 at 5:00PM, R2 was noted unresponsive and unable to obtain vital signs. R2 was pronounced dead on 10/02/2020 at 5:05PM by hospice care staff. Death report for R2 indicated immediate cause of death was congestive heart failure with underlying causes listed as atrial fibrillation and hypertension. Based on all information obtained, there is insufficient evidence to support the allegation, therefore the above allegation “facility did not provide adequate care and supervision, which resulted in R2’s death” is deemed UNSUBSTANTIATED at this time. Additionally, the complaint the Department received on 10/26/2020 contained an allegation that the “facility is retaining a resident with active tuberculosis (TB).” LPA Dulek had received a phone call from Administrator Jade Alma-Harris on 10/20/2020 indicating Resident #3 (R3) had recently moved into the facility. Upon admission, R3’s physician’s report indicated no evidence of TB, but did not indicate a date a TB test was administered. Administrator Alma-Harris confirmed R3 had resided at another RCFE prior to moving into the facility and had no known TB exposure. Due to the physician’s report missing a TB test date, the resident had an on-site visit from a mobile doctor. The doctor took a chest x-ray and the results appeared questionable, so the doctor conducted a blood test. Results of the blood test indicated a TB infection. Ms. Alma-Harris contacted Ventura County Public Health, who directed the facility to retest R3, as R3 had no known TB Report Continued on LIC 9099-C exposure and the result may be due to latent TB infection or a false positive. The following day, on 10/21/2021, a doctor conducted additional testing and confirmed R3 did not have any evidence of active TB. LPA Dulek reviewed records provided for R3 and confirmed R3 had a negative TB test on 10/21/2020. Based on all information obtained, there is insufficient evidence to support the allegation, therefore the above allegation “facility is retaining a resident with active tuberculosis” is deemed UNSUBSTANTIATED at this time. The complaint also contained an allegation that the facility has a scabies outbreak. LPA Dulek, along with Executive Director Jill Ford reviewed electronic medical records for 28 of 28 residents residing in the Memory Care unit during the time period the complaint was received. Although many resident medical records and care notes did indicate residents had a rash, there was no indication of a scabies diagnosis for any of the 28 resident records reviewed. Interview with Ventura County Public Health (VCPH) indicated there were no reports to VCPH at the time of the allegation. VCPH nurse indicated Permetherin cream is used to treat scabies infections and is only prescribed for scabies. 3 of the 28 resident records reviewed indicated Peremethrin cream was prescribed to the resident, however all 3 of 3 residents’ physicians indicated an alternate diagnosis. One indicated a diagnosis of dermatitis, one indicated a mild rash, and the other indicated primary care physician “does not believe the resident has scabies.” Based on record review, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation. Therefore, the allegation that “facility has a scabies outbreak” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided via email.