complaint·May 19, 2025

Interviews and a review of records showed that Resident 2 (R2) was prescribed a Fentanyl 50 mcg/hour transdermal patch, with instructions to apply one patch topically every 72 hours. Records indicate that the patch was applied on 05/07/2024 at 8:00 a.m., and again on 05/10/2024 , at 8:00 a.m. R2 was admitted to a local hospital on 05/12/2024, and returned to the facility at approximately 9:45 p.m. that same day. There is no documentation showing that the patch was replaced on 05/13/2024, as would have been scheduled based on the prescribed 72-hour cycle. However, records do indicate that the patch was replaced on 05/16, 05/19 and 05/22 each at 8:00 a.m. Staff interviews did not confirm whether the patch was replaced on 05/13/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation above. Therefore, the allegation "Staff did not provide medical attention to resident in a timely manner" has been deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided. It was reported that "Resident sustained pressure injury while in care" and "Staff did not rotate and repositioned resident" as it was alleged that Resident #1 (R1) sustained pressure injuries due to staff neglect and failing to rotate and reposition R1. Interviews conducted and records review revealed R1 was admitted into the facility on 05/24/2023. LPA's records review of hospice records dated from 06/24/2023 - 01/26/2024, revealed R1 was serviced by Hospice at least two (2) times a week for routine services such as showering and to observe wound on left ankle. Records reviewed from 01/29/2024, revealed R1 was observed with Stage III pressure injury on coccyx. The records did not indicate any concerns for facility staff not repositioning R1 in a timely manner at this time. LPA's interview with six (6) staff who worked often with R1 confirmed R1 was checked on at least every (2) hours. When R1 was observed by staff it would typically involve, observing any bandages, ensuring they were dry, elevate their legs if necessary and address any concerns the R1 might express. Each staff did not express any concerns for staff not repositioning R1 in a timely manner at this time. LPA's interview with the spouse of R1, Resident #2 (R2), revealed that they have observed staff check on R1 throughout the day and reposition R1 in a timely manner. R2 did not express any concerns for staff not repositioning R1 in a timely manner at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Resident sustained pressure injury while in care" and "Staff did not rotate and repositioned resident" is deemed Unsubstantiated at this time. It was reported that "Lack of supervision resulting in resident falling causing injuries" as it was alleged that R2 was allowed to walk out of the facility without supervision resulting in a fall. LPA records review of R2's Physician’s Report dated 06/11/2024 indicated that R2 is able to leave the facility without assistance and does not require staff support for ambulation. LPA's interview with revealed that R2 requested to go outside, and there was no indication that R2 required staff assistance or was restricted from doing so. In an interview with R2, they stated they felt well enough to go outside for fresh air. R2 reported that while walking, they were not paying attention and tripped over the uneven space between the grass and the cement walkway. R2 recalled that bystanders and an off-duty employee assisted them in getting up. The off-duty employee then accompanied R2 back into the facility, where R2 received first aid. R2 did not express any concerns regarding staff supervision, noting that they exited the facility independently and the fall occurred due to their own inattention. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Lack of supervision resulting in resident falling causing injuries" is deemed Unsubstantiated at this time. It was reported that "Staff does not assist resident with daily needs" as it was alleged that staff refused to assist R2 with showering, dressing and overall care. Records review and interviews confirmed that R2 was admitted to the facility on 05/24/2023. According to R2’s Individualized Service Plan (ISP) dated 05/27/2024, R2 requires hands-on assistance with the following: Dressing and grooming – Caregivers are responsible for setting up grooming materials and assisting as needed, Bathing – Caregivers provide hands-on assistance for all showering/bathing needs, scheduled 1 to 2 times per week and Toileting – R2 is occasionally incontinent and may require staff assistance with toileting. LPA's interview with R2 revealed that staff consistently assist with their daily needs. R2 confirmed receiving showers at least twice weekly and stated that staff greet them each morning, help select clothing, and escort them to meals. R2 did not express any concerns regarding the level or timeliness of staff assistance. Additionally, a review of facility records and staff interviews confirmed that residents are provided care in accordance with their individual care plans. LPA also interviewed seven (7) residents currently residing in the facility. All residents interviewed stated they had no concerns about staff assistance with daily needs. Each resident also confirmed that staff respond to requests for help in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation "Staff does not assist resident with daily needs" is deemed Unsubstantiated at this time It was reported that "Staff not checking resident's blood pressure as required" as it was alleged that staff did not check R2's blood pressure twice daily as prescribed. Interviews conducted and records review revealed, on 04/16/2024, R2 received an order to "Check blood pressure twice a day through 05/08/2024 - keep log of readings" . LPA's records review revealed that from 04/16/2024 to 05/08/2024, R2's blood pressure was typically checked twice a day—once in the morning between 7:30 a.m. and 11:00 a.m., and once in the evening between 5:00 p.m. and 6:00 p.m. Additionally, on 05/20/2024, a prescription was issued for R2 to have their blood pressure checked daily. Records reviewed from 05/20/2024 to 06/02/2024, revealed R2’s blood pressure was generally checked around 8:00 a.m. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff not checking resident's blood pressure as required “ is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.