374603617-5-17-2024-08-AS-JLOT-D5KT6R-20240524142734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603617
Report Date: 05/17/2024
Date Signed: 05/17/2024 10:06:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2023 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20230920100922

FACILITY NAME:	TORREY PINES SENIOR LIVING		FACILITY NUMBER:	374603617
ADMINISTRATOR:	MCDONALD, JASON		FACILITY TYPE:	741
ADDRESS:	13101 HARTFIELD AVE		TELEPHONE:	(858) 259-2222
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92130
CAPACITY:	125	CENSUS: 0	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Facility Closed- Mailed to Last Known Licensee Address		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Neglect resulted in serious bodily injury.

INVESTIGATION FINDINGS:

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The following determination of findings has been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegation. The facility closed on 03/29/2024, due to a change of ownership, and this report was mailed to the last known address on record for the former licensee regarding the findings.

On 9/20/23 the allegation, "Neglect resulted in serious bodily injury" was made against the Licensee due to Resident 1 (R1) suffering unstageable pressure wounds. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. R1 experienced a number of co-morbidities, including Hypertensive Heart, Sepsis, Gout to the left lower extremity, chronic Osteomyelitis to the left lower extremity, chronic kidney disease, Prostate Cancer, amputation of right leg below the knee, cardiac pacemaker, and Atherosclerosis of the left leg with ulceration. R1's care plan required for R1 to be turned and repositioned every two (2) hours to offload pressure on specific body parts, and for staff to monitor/treat their skin in order to heal existing pressure wounds and prevent future wounds.
(Continued on LIC9099 p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230920100922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TORREY PINES SENIOR LIVING	FACILITY NUMBER: 374603617
	VISIT DATE: 05/17/2024

NARRATIVE

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(Continued from LIC9099 p.1)

Interviews with facility staff and nurses revealed that R1 did not like being repositioned, often refusing staff attempts. Staff informed that they documented all of R1's refusals to show that attempts were made. Staff interviews further revealed that R1 had a mattress designed to reduce pressure injuries, and that staff educated R1 on the risks of not allowing themselves to be repositioned regularly.

Outside source interviews revealed observations of R1 readjusting themselves back to lying on their back
right after staff positioned them to relieve the pressure on their wounds. Outside sources further informed that staff were very attentive and checked on R1 every two (2) hours, but R1 refused to follow the doctor's recommendations regarding their pressure injuries. Outside sources corroborated staff statements that R1 often refused to be moved from their bed and also regularly declined baths. Outside sources did not have concerns regarding R1's care at the facility, stating that R1 enjoyed living at the facility and staff provided good care.

Review of facility progress notes and Home Health visit documentation showed that R1's Home Health agency and facility staff were aware of R1's pressure sores, documented their efforts to assist in healing them, and were in ongoing communication with each other regarding R1's care. R1's medical records, corroborated by staff and outside source interviews, further revealed that R1's poor circulation post amputation contributed to the deterioration of their tissues. R1's Physician's Report, skilled nursing discharge summary, and Home Health Visit Note Reports revealed that pressure sores existed prior to R1's admission to the facility.

Interview with R1 corroborated staff interviews, outside source interviews, and records review. R1 stated they preferred staying in bed most of the time and regularly refused being repositioned by staff and taking baths. R1 acknowledged that their refusals for care were causing their pressure sores to worsen.

Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation of "Neglect resulted in serious bodily injury" occurred, therefore the allegation is UNSUBSTANTIATED. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the facility.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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