374604057-8-26-2021-08-AS-IESA-C774M4-20210924191254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 08/24/2021
Date Signed: 08/26/2021 03:33:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/18/2020 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20200618142043

FACILITY NAME:	ELMCROFT OF LA MESA		FACILITY NUMBER:	374604057
ADMINISTRATOR:	HEBNER, WES		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY:	56	CENSUS: 26	DATE:	08/24/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Executive Director, Wes Hebner		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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-Resident was neglected, resulting in a pressure injury
-Unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA identified herself and met with Executive Director, Wes Hebner.

During the investigation, the Department briefly toured the facility, requested records, and conducted interviews with staff, residents, and outside sources. It was alleged Resident #1 (R1) was neglected, resulting in a pressure injury. R1 sustained a Stage II pressure injury that progressed to Unstageable. The Mayo Clinic defines pressure injuries can be classified into four (4) stages of increasing depth and severity, known as Stages one (1) thru four (4). However, they also have additional stages that exist known as unstageable injuries. Unstageable injuries are described as covered by dead tissue or eschar that obscures the ulcer base. R1’s Physician’s Report dated 11/21/19 indicated R1 used a walker and was independent with showering, toileting, dressing/grooming, and feeding, but required assistance with medications. However, R1’s initial assessment documented on the facility’s Level of Care Chart Details, dated 11/25/19 indicated that R1 required assistance with showering, toileting, dressing/grooming, medications, and mobility to include escorting by staff. Continued on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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-20200618142043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMCROFT OF LA MESA	FACILITY NUMBER: 374604057
	VISIT DATE: 08/24/2021

NARRATIVE

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The facility was using an outside nursing agency due to staff shortage caused by the Pandemic. A review of the facility’s records reflected the pressure injury on the left hip was observed by the facility nurse on 04/28/20 as a Stage II pressure injury. On 04/28/20, the facility contacted R1’s Primary Care Physician (PCP) but was told they were unavailable. Therefore, the PCP’s Physician’s Assistant (PA) advised the facility to follow their protocol for wound care. However, the facility did not provide the outside nursing agency with their wound care protocol. On 05/01/20, the facility staff documented in the resident notes that R1’s pressure injury was now unstageable on R1’s left hip area, and reported it to the PA. Facility’s Resident’s Notes dated 05/01/20 indicated Home Health (HH) would be coming to evaluate R1, as HH’s schedule allows. On 05/06/20, the facility contacted the PCP’s office and was notified HH was denied. The facility did not have a physician’s order to follow or a plan of care for R1’s left hip pressure injury. However, the facility continued to address the pressure injury with no wound care instructions or supervision of a wound care nurse. On 05/08/20, the facility’s nurse provided wound care and observed the pressure injury had a yellow wound bed, leaking pus, and the edges were red and warm to the touch. Interviews conducted, confirmed the nurses from the nursing agency were not wound care nurses but continued to provide wound care for R1’s pressure injury. Further interviews revealed the wound bed was covered with necrotic tissue and eschar. In addition, staff interviews revealed there were no official medical orders, and the facility did not have the proper equipment for wound care. Not until 05/11/20, was R1 sent to the hospital for evaluation. On 05/11/20, R1 was admitted to the hospital, the hospital’s documentation reflected R1’s pressure injury appeared to be an unstageable wound from what was categorized as a Stage II upon admission. R1’s pressure injury was not appropriately being cared for by facility staff, due to no involvement of a skilled professional with a background in wound care or a plan of care to follow for the pressure injury. The facility failed to meet the needs of R1 by allowing the pressure injury to go untreated by a skilled professional with a background in wound care from 04/28/20 thru 05/11/20 (14 days).

It was also alleged, R1 was unlawfully evicted. R1 was sent to the hospital for evaluation of their pressure injury on 05/11/20. Once R1 was ready to be discharged from the hospital back to the facility, facility staff denied R1’s return to the facility with the pressure injury. R1 was not receiving hospice services when the pressure injury was initially observed by facility staff. Facility’s Resident Notes dated 05/25/20, indicated R1 was placed on hospice services while in the hospital and ready to return to the facility. It also stated the wound was still unstageable. The facility had a hospice waiver in place. Facility records reflected the facility nurse would have to check with facility’s management if they will be allowed to accept R1 back into the facility. Facility’s Resident Notes dated 05/26/20, indicated they would not be able to accept R1 back due to Covid-19 situation at the facility, even if R1 was on hospice.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200618142043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMCROFT OF LA MESA	FACILITY NUMBER: 374604057
	VISIT DATE: 08/24/2021

NARRATIVE

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Staff interviews revealed R1 was not allowed to return to the facility until R1’s unstageable pressure injury was healed. Outside source interviews confirmed the denial of R1’s return to the facility, until the pressure injury was healed. Hospital records indicated “they report that memory care facility will not take patient back because of the decubitus ulcer.” A decubitus ulcer is also identified as a pressure injury. R1 was not served a written 30-day notice of eviction, as outlined in Title 22 Regulations. Instead, the facility staff provided a verbal notice to the hospital that R1 could not return to the facility until the pressure injury was healed.

Based on interviews conducted and records reviewed, the facility failed to seek timely medical treatment for R1, resulting in an unstageable pressure injury. Also, R1 was unlawfully evicted when facility staff did not allow R1 to return to the facility after hospital discharge. Therefore, there is enough corroboration and evidence to demonstrate staff failed to seek medical attention in a timely manner for R1 when there was a change in condition due to a prohibited health condition; and the unlawful eviction. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1].

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200618142043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMCROFT OF LA MESA	FACILITY NUMBER: 374604057
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/25/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Executive Director agreed to ensure that all staff receive training, provided by an outside vendor, pertaining to contacting emergency medical services. The Executive Director agreed to provide the date of scheduled training and provide proof of training to Community Care Licensing
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not contact 911 or obtain emergency medical services for 1 [R1] out of 26 residents. This posed an imminent threat to the health of R1.	8 9 10 11 12 13 14	upon completion, which will be scheduled to occur within two weeks. This is an amended version of the original report created on 08/24/21.
Type A 08/25/2021 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	Eviction Procedures- If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Executive Director agreed to review CCR 87224 - Eviction Procedures and provide self-certification to CCL by POC due date. This is an amended version of the original report created on 08/24/21.
	8 9 10 11 12 13 14	Based on interviews and record review, Licensee did not provide 1 [R1] of 26 residents with a written 30-day eviction notice for a reason(s) listed in regulation. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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