Assistant Administrator S1 stated that a resident arrived at the facility on 09/28/2020 with a wound. According to Administrator, wound care was being provided by Pacific Pace, and a referral to Mission Hospice was completed on 10/01/2022. Wound care was approved effective 10/03/2020. LPA reviewed facility progress notes and Hospice documentation for R1 dated 10/06/2020 through 03/21/2021. Documentation of all care for R1 was received. Documentation from Hospice detailed daily wound care performed which included: removing soiled dressings, cleaning the wound(s), applying medicated creams, and wrapping the wound. Five of five staff (S1-S5) stated that no resident had developed a pressure injury while in care. LPA interviewed two residents with current wounds, and two of two residents (R2-R3) stated they arrived at the facility with wounds, and did not develop wounds at the facility. R1 was admitted on 09/28/2020 to facility, and LPA was unable to interview R1 due to R1’s passing on 04/24/2021.

LPA also interviewed an additional five residents (R4, R5, R6, R7,R8) who stated they did not know of any residents with pressure injuries, and they do not have pressure injures. LPA reviewed documentation from Pacific Pace and Hospice, along with R1’s medical records that documented R1’s wound(s) prior to being admitted to facility. Interview with overseeing wound care physician stated that R1 did not develop any pressure injuries while in care at facility. Also, no documented evidence was discovered that indicated R1 developed pressure injuries while in care at the facility. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

Regarding Allegation: Staff are not preventing the spread of infection. It is alleged that facility did not prevent the spread of infection, and that bodily fluids on the floor of resident’s room was being stepped on by staff, and taken to other rooms of facility.

Assistant Administrator S1 stated that they have an Infection Control Plan. LPA reviewed Infection Control Plan, and all five of five staff stated that they follow the Infection Control Plan to prevent infection. LPA observed a large bin in a secured area where all bio hazard material is place for disposal. Five of five staff stated there are specific procedures to prevent the spread of infection, and denied walking, or seeing others walk, or step into bio hazard liquids. Two of two residents who are currently receiving wound care stated, all bio hazard material is disposed in a proper manner. Residents (R4, R5, R6, R7, R8) stated that facility does everything they can to prevent the spread of infection. LPA toured facility with Assistant Administrator and did not see any infectious material or fluids anywhere in facility rooms, or common areas.

(continued on 9099C)

Regarding Allegation: Staff are retaining a resident that requires a higher level of care. It is alleged that facility retained a resident that required a higher level of care due to severity of wounds.

Assistant Administrator (S1) stated facility does not retain residents that require a higher level of care. S1 stated R1 entered the facility at a Level 2, and the facility can care for residents up to Level 4. When R1 arrived at the facility on 09/28/2020, the facility and Pacific Pace provided care for resident’s needs. On 10/01/2020, a referral was provided for Mission Hospice to provide wound care to R1. Five of five staff interviewed stated they have not seen or know of any residents that require a higher level of care residing at facility. Five of seven residents stated that they are happy with the care they receive, and that no other residents require a higher level of care. Two residents stated that one resident is loud and wished they had a room further away, but not sure resident requires higher level of care. LPA Interviewed R1’s Hospice physician on 05/01/2023, and medical records for R1 were requested at that time. On 5/15/2023, physician sent email with additional information on wound care provided to R1. On 5/22/2023, R1’s records from WelbeHealth were transmitted via secure email to LPA. Physician overseeing wound care for R1 communicated to LPA that Physician was aware of R1 wound(s) on 10/01/2020, and that appropriate treatment was provided. R1’s wound care physician identified maggot infestation on 10/07/2020, and provided appropriate treatment at that time. Facility contacted Pacific Pace regarding possible MRSA infection on 10/06/2022, and treatment was prescribed according to progress notes in R1’s file. LPA reviewed all medical records gathered from interviews, emails from physician, and medical records obtained from WelbeHealth in regard to the stage and/or diagnosis of R1’s wound(s). There was no corroborating evidence indicating the facility accepted and/or retained a resident with a prohibited health condition, that the maggot infestation was due to neglect on part of the facility, or that the facility failed to contact R1’s physician. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

(Continued on 9099C)

Assistant Administrator stated that the facility, Pacific Pace, and Mission Hospice was providing resident with proper wound care. LPA reviewed facility progress notes for R1 dated 10/06/2020 to 03/21/2021, and documentation specified all care, including wound care, that was provided to R1. Four of four staff interviewed stated that most wound care is provided by outside agencies such as Home Health or Hospice, and facility ensured that R1 received proper wound care while at facility. Two of two residents that currently require wound care stated that they were receiving proper wound care, and they were satisfied with the services. Additional five residents (R4, R5, R6, R7,R8) stated they do not know anyone who receives wound care, and are unable to answer the question. R1’s physician stated that proper wound care was provided to R1, with the exception of when R1 refused wound care. According to email sent to LPA from R1’s physician, R1 was enrolled in Pacific Pace from 10/1/2020 to 4/24/2021. R1 received wound care from Mission Hospice on the following dates: 10/23/2020, 10/24/2020, 10/25/2020, 11/10/2020, 11/13/2020, 11/14/2020, 11/15/2020 11/17/2020, 11/20/2020, 11/21/2020, 11/22/2020, 11/24/2020, 11/26/2020, 11/30/2020, 12/1/2020, 12/4/2020, 12/5/2020, 12/6/2020, 12/8/2020. R1 began receiving wound care Monday through Friday from 12/20/2020 to 1/4/2021. R1 cancelled wound care on11/1/2020, and care was also cancelled due to hospital admissions on: 12/11//2020 to 12/20/2020; 2/18/2021 to 2/23/2021, and on 3/29/2021 to 4/5/2021. R1 adamantly refused SNF placement after hospitalization in December 2020. R1 was advised of the benefits of rehabilitation and wound care. Wound care was provided by WelbeHealth, and Pacific Pace on: 10/8/2020, 10/9/2020, 10/13/2020, 10/14/2020, 10/15/2020, 10/26/2020, 10/28/2020, 10/29/2020, 11/2/2020, 11/4/2020, 11/5/2020, 11/11/2020, 11/12/2020, 11/16/2020, 11/18/2020, 11/19/2020, 11/23/2020, and refused on 11/25/2020. Wound care was cancelled by R1 on the following dates: 10/16/2020, 10/19/2020, 10/21/2020, 11/9/2020. According to R1’s Preadmission Assessment dated 09/28/2020, R1 had a history of refusing showers and care services.

Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.