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13 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint received by the Department on 5/19/2022. LPA met with Kathleen Gilbey, Administrator, and explained purpose of inspection. LPA later met with Ron Cheek, Memory Care Director, who assisted in providing additional documentation as requested, pertaining to resident (R1). Prior to initiating today's inspection, LPA completed required COVID-19 screening protocols and was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and wore a surgical mask.
During the investigation, LPA interviewed Administrator, (2) prior Memory Care Directors, current Memory Care Director, (6) Med-Tech/Caregiver staff, Activity Coordinator, Ombudsman and resident (R1). LPA was unable to conduct (2) additional staff interviews. LPA reviewed documentation including, but not limited to: physician’s report, Care Plan (9/5/22) Medication Administration Record from April -September 2022, resident charting notes, multiple fax communications to physician, physician’s orders, home health records and hospital discharge papers. The results of the investigation are as follows:
cont on 9099C(1).. |
| Substantiated | Estimated Days of Completion: |
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13 | During the investigation, LPA interviewed Administrator, (2) prior Memory Care Directors, current Memory Care Director, (6) Med-Tech/Caregiver staff, Activity Coordinator, Ombudsman and resident (R1). LPA was unable to conduct (2) additional staff interviews. LPA reviewed documentation including, but not limited to: physician’s report, CARE PLAN, Medication Administration Record from April -September 2022, resident charting notes, multiple fax communications to physician, physician’s orders, home health records and hospital discharge papers. The results of the investigation are as follows:
Allegation: Facility is not properly treating resident's wounds. Allegation refers to client has open wounds and blisters that are not being treated appropriately.
cont on 9099C(1).. |
| Unsubstantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | 9099A-C(1)...Resident care notes from 8/13/2021 indicate resident was sent out to the hospital for further evaluation of her chronic back pain and sacral ulcer. Discharge papers show resident returned to the facility the same day with pain medications and information about preventing pressure injuries. Home health records show on 8/14/2021 resident was treated for a Stage 2 pressure ulcer on mid upper buttocks and complaints of mild pain and was seen again on 8/21/2021 for continued wound care to Stage 2 and for a Stage 1 on the right heel. Resident received a prescription for Calmoseptine ointment on 8/24/2021 to be applied twice daily until healed, was seen again on 8/27/2021 to assess and instruct regarding existing (2) wounds and was discharged on 9/3/2021 with wound care instructions of “frequent position changes, continue applying moisture barrier cream with incontinence skin care”, noting resident had a “Stage 2 inner gluteal pink skin, not open with flaky skin”. Physician's fax report sent on 4/15/22 by a prior MCD to resident's primary care physician at the time, states, in part staff has noticed an increase in redness and some small open areas forming.. we continue to use the calmoseptine in those areas but little to no effect" and resident is in pain and agitated.. Physician's response received on 4/18/22 states resident has an order for Norco already and to add Tylenol twice daily. An antibiotic treatment of 14 days was prescribed on 4/20/22.
MAR documentation shows Amox Clav 875-125 mg tablets were given for 14 days, starting on 4/21/22 through 5/4/22 and Clotrimazole-Betamethasone creme was applied twice daily, for 20 days starting on 4/27/22 in the evening.
Physician's fax report sent on 5/9/22 describes resident to have (2) open sores in her groin area and (2) that are bleeding and physician's fax report sent on 5/19/22 reports resident has "redness, bumps and peeling under both breasts" and requests another order for Clotrimazole-Bethamethsone cream as the 20 days has finished. Resident was sent to the emergency room on 5/20/22 and received a prescription for Nystatin topical powder and Keflex capsule.
MAR shows Keflex was administered 3 times daily for 7 days, as prescribed, effective 5/21/22; however, resident did not receive the prescribed cream on 5/17/22 due to needing a refill. A new order was written on 5/24/22 but was not given on the evening of 5/30/22 and on 5/31/22 due to waiting for a medication delivery.
Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED.
cont on 9099A(C2).. |
NARRATIVE |
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32 | 9099C(2).. Physician’s fax report dated 12/25/2021 notes while toileting resident, staff “noticed a large hand sized patch of blotchy red skin under her left breast… and a dime sized bump” not previously seen before. A prior MCD stated “the rash was "on her arms and thighs", and "the rash did improve with bathing". The prior MCD commented it is "definitely a fungal rash" and also “she had a yeast under her breast”. Another MCD stated that resident resident enjoyed the jacuzzi and would sometimes cooperate better with staff than when trying to bathe her in the shower. A caregiver staff confirmed on 5/24/22 that resident did go to the ER "because of the rash" as the the NOC shift Med-Tech said resident was complaining off pain and the rash was "itchy and burning".
LPA reviewed note from resident's physician, written on 6/17/22 following visit on 6/8/22, which says “perineal rash is likely a fungal dermatitis due to poor hygiene (wears Depends) and her poorly controlled DM (Diabetes Mellitus)". Physician's report, dated 9/8/22, says resident has dermatitis associated to incontinence. Current MCD stated on 9/22/22 resident's rash " is better and staff is still using creme". MAR documentation shows Menthol-Zinc Oxide ointment, or Calmosepine ointment, was prescribed on 12/14/2021 and was administered starting on 9/8/22, for the month of September, when resident returned to the facility.
A prior MCD indicated that resident would refuse showers regularly and she "finally got her to take one" and resident "would scream and scream" in the shower when the water started. Staff interviews confirmed that if a resident refuses on a regular basis, not all staff will try and redirect the resident to be able to give the shower. LPA finds this allegation to be SUBSTANTIATED.
Allegation: Resident's hygiene needs are not being met. Complaint alleges client has only been showered 3 times in the past 4 months.
One staff stated resident was not showered the entire month of Sept and went 6 weeks without shower. Another staff stated "the challenge is she resists, she needs a 2-person assist and she would scream "don't touch me". A third staff stated she and another staff gave resident a shower recently and it was difficult", stating "it's extremely hard to care for (R1)" and she is "definitely a 2-person assist" for the last year. A fourth staff stated "she never really wanted to shower" and she would refuse and went weeks without receiving a shower" and "some of the caregivers on the NOC shift gave her a shower because they couldn't stand seeing her unshowered for so long. Several staff stated they would report to the lead- Med-Tech, verbally that resident was not showered and nothing was done.
9099c-(3) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
10/13/2022
Section Cited
CCR
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7 | 87464 Basic Services. (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by:
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7 | Licensee/Administrator already conducted training with "pm" and "NOC"caregiver staff.
Resident is now receiving daily showers, Mon-Fri, effective 3 weeks ago, and has a shower chair and is cooperating better. Time of shower has changed and resident is doing better. MCD will continue to consult with the Health and Services Director. |
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14 | Based on interviews conducted, the Licensee did not ensure that resident (R1) received scheduled showers, twice weekly, on a consistent basis, from May 2022- September 2022, which posed an immediate health and safety risk to residents in care. | 8
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Request Denied
Type B
10/31/2022
Section Cited
CCR
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7 | 87307 Personal Accommodations and Services-(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: This requirement is not met as evidenced by:
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7 | Resident received a shower chair end of September 2022. Licensee/Administrator agree to conduct staff training on proper protocols in reporting issues to managers.
Documentation of agenda/attendees to be provided to CCLD by 10/31/22. |
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14 | Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) had a shower chair to use for assistance during bathing from on/around April 2022- September 2022, which posed a potential health and safety risk to residents in care. | 8
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