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In addition, it was reported that during the incident, R1 tripped over a case of water located near their closet, where R1 was changing. Medical services were contacted and R1 went to local hospital. Medical records revealed that R1 was diagnosed with a left hip fracture. Interviews confirmed that around 9:00 am on February 16, 2021, R1 received a delivery of two cases of bottled water which were taken to R1 room. These cases were observed by staff on date of incident. In addition, at least one staff reported that regarding R1, it was not uncommon for cases of water to be placed in front of closet door in R1 room. Department investigation further revealed that at least four staff entered R1 room on February 16, 2021, following delivery of cases, but the cases were not moved from placement on floor near closet where R1 fell. The cases remained in this area utilized by R1. According to interviews and facility records, R1 was visually impaired (legally blind) and utilized walker for mobility. Records also revealed that R1 required assistance with bathing, dressing (assistance with putting pants on), and toileting (some assistance). R1 Admission agreement includes those basic services such as safe and healthful living environment for all residents…will be provided. The preponderance of evidence found during investigation supports that facility staff did not provide accommodations for a safe and healthful environment for R1. On February 16, 2021, for an unknown period of time, at least one case of water was left near R1 closet. This case created a tripping hazard to R1, who was legally blind. As a result, R1 sustained a fracture as a result of experiencing a fall and tripping over the case of water. The allegation, Licensee did not ensure safe accommodations resulting in R1 sustaining an injury is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Roland Gandy, Executive Director. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The allegation that facility is unsanitary. LPAs toured the facility with Roland Gandy, Executive Director. Based on LPAs observations the facility is clean and sanitary. Staff does maintain the facility by keeping up with the cleaning at all times. Based on evidence obtained during the investigation, the above allegations are Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed, and a copy was provided to Roland Gandy, Executive Director at the conclusion of the visit.

A review of home health services records was conducted. An assessment document dated 08/23/2021 revealed the reason for the assessment was for discharge from agency. The certification period was from 06/25/2021 to 08/23/2021 and the date the assessment was completed was on 08/19/2021. Under the Integumentary status heading, the question on whether R1 had at least one unhealed pressure ulcer at State II or higher or designated as unstageable was entered as no. The assessment allows the user to enter the number of unhealed pressure ulcers at each stage and nothing was entered. Further, the number of current Stage I pressure ulcers was listed as zero. A note reads “Patient has no pressure ulcers or no stageable pressure ulcers.” The discharge da te is listed as 08/19/2021. R1 was interviewed where it was revealed R1 was unable to reposition in bed. R1 had a call button where they could call for staff assistance. Interview revealed R1 would be repositioned in bed one time in the morning and sometimes when staff would come to change R1. It was further revealed caregivers would clean R1’s sores put medication on them. The interview revealed R1 was not repositioned frequently. The facility was not able to provide documentation to show how frequently R1 was repositioned by staff. Hospital records were reviewed. The Patient Education & Visit Summary revealed R1 was seen on 08/27/2021 for bleeding from the coccyx. Discharge notes read follow up with Primary Care Provider (PCP) is needed. Staff interview revealed that a review of hospital discharge paperwork is usually done along with contact with PCP for wound assessment. According to information revealed in the interview, it did not look like the review and contact with PCP was done. A staff interview revealed a new care plan is developed when pressure injuries are documented. Based on interviews, the facility did not obtain an updated Physician’s Report nor did they update R1’s care plan. Facility Charting Notes revealed seven (7) notes relevant to this investigation. On 08/27/2021, it noted R1 had just returned from the hospital with a dressing in place on the buttocks. On 09/01/2021, it noted the wound on the buttocks did not have a dressing when changing R1. Brief had blood on it. Staff changed and repositioned R1 and left pendent within reach. Staff would continue to monitor. On 09/15/2021 at 1:53am, it was noted that staff responded to a pendant call and found R1 sitting on the floor. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff noted R1 had been feeling pain on her buttock due to bedsore and had tried to roll on their side but ended up rolling off the bed. On the same day of, 09/15/2021 at 5:38PM, there is another note where staff note the bruising again and indicated R1 had been given pain medication. It was further noted, R1’s buttocks area cleaned and dry, barrier cream applied, bandage replaced and resident was repositioned frequently during the shift. On the charting note dated 10/27/2021, it reads “resident has open bleeding bed sores”. There are no additional notes until 11/26/2021. The charting note dated 11/26/2021, indicates the dressing for R1’s buttocks was not changed during the caregiver’s shift and R1 did not remember if it was done during the AM shift. The caregiver noted R1 was already in bed and would not allow the caregiver to change it. The caregiver further noted they would notify the AM nurse to change the dressing in the AM. On the charting note dated 12/18/2021, R1 was sent to the hospital around 7am due to excessive bleeding from the coccyx wound. It was further noted on the same day, R1 was admitted to the hospital and wound care was being provided to stop the bleeding and tunneling of the wound. According to a staff interview, staff reported they faxed R1’s Primary Care Physician (PCP) on 12/14/2021 to request R1 receive Home Health Services regarding “Stage II” pressure injuries to the right and left buttocks. According to staff during the, the PCP informed the facility that R1 would need to be seen in-person first. The in-person appointment never took place because records show that R1 was sent to the hospital on 12/18/2021. A review of the Physician Fax and Visit document dated 12/14/2021 corroborated this information. The response from physician was dated 12/15/2021 and indicated R1 needed to be seen for an office visit first. A review of hospital records was reviewed. They revealed that R1 was admitted to the hospital on 12/18/2021. The diagnosis was decubitus ulcer of buttock. The Photographic Wound Documentation Form dated 12/18/2021, in the emergency department, revealed the wounds were present on admission on the buttocks, bilateral. It was identified as pressure injuries with a diagnosis of decubitus ulcer. The Photographic Wound Documentation Form dated 12/19/2021 indicated, the pressure injuries, present on admission, were staged at Stage III on the right and Stage II on the left. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 History and Physical/Admission Notes dated 12/18/2021 read Chief Complaint is R1 was brought in by facility with complaint of coccyx pain that is bleeding. R1 denied trauma and states it happened while in the bathroom. The section titled History of Present Illness read R1 presents with buttock decubitus ulcers that have been bleeding, ER staff concerned that R1 may not be getting optimal care at R1’s current facility. Emergency/Urgent Care record dated 12/18/2021 indicated the Medical Decision Making section noted they were unable to arrange for safe discharge with home health given concerns for neglect. Wound Care notes dated 12/19/2021 revealed right buttock stage III was sized at 2x2.5x.1 cm and left buttock stage II was sized at 4x2x.1 cm. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on records review and interviews, there was no information found to show that any attempts were made by facility staff to arrange for medical care and follow up with the PCP, as recommended in the discharge notes from 08/27/2021 until 12/14/2021. An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D and appeal rights. In addition, an immediate civil penalty of $500 is being assessed. The LIC 421 was also reviewed, provided along with appeal rights. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

On April 15, 2024, Licensing Program Analyst (LPA) Javina George arrived at the facility to conduct an unannounced annual inspection. LPA met with Administrator, Roland Gandy and explained the purpose of the inspection. The facility serves residents that reside in assisted living, memory care and independent living. The residents range from being aged 60 and over, and are non-ambulatory. The facility has an approved hospice waiver for 18 residents. Physical plant: during today's visit LPA conducted a tour of the interior and exterior of the facility. The facility was observed to be clean, clutter and odor free. LPA observed a 7-day supply of non-perishable and 2-day supply of perishable foods were present. Six (6) resident apartments were inspected and observed to be clean and furnished with a bed, chest of drawers, chairs and adequate lighting. The bathrooms were observed to be clean and equipped with grab bars in the shower. The medications and hazardous items were stored in a locked area, and are inaccessible to residents in care. The hot water tested in multiple apartments and were found to be within regulatory limits ranging from 105.9-113.5 degrees Fahrenheit. Carbon monoxide & smoke detectors were tested and observed to be operable. Delayed egress devices were operable on all exit doors. Resident call buttons and pendants were tested and observed to be operable. There are no known guns or ammunition on the premises. There are were no bodies of water were observed. Records review: Five (5) resident files were reviewed, and all 5 resident files were observed to have the required documentation such as medical assessments, admission agreements, pre appraisal assessments. Five (5) staff records were reviewed and all #5 contained the required training, however there were only two (2) staff observed to have current first-aid/CPR certification for the entire facility. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted where this report, 809D, LIC9098 proof of corrections form, LIC 811 and appeal rights were discussed with and provided to the Roland Gandy, Executive Director.