374604060-4-11-2024-08-AS-MSTC-D4U2EE-20240430171947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604060
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:31:10 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
11/01/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20211101091549

FACILITY NAME:	GROSSMONT GARDENS		FACILITY NUMBER:	374604060
ADMINISTRATOR:	KAITLIN RUDOLPH		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	0	CENSUS: 0	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	N/A, Report Mailed to Licensee		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Licensee neglect, contributing to resident developing pressure injury(ies).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegation. Since the facility closed on 05/04/2023 due to a change in ownership, the allegation finding was delivered to Licensee via USPS certified mail.

The Complainant alleged Licensee’s staff neglected to turn and reposition Resident #1 (R1) in bed, which contributed to R1 developing pressure injuries to their skin/body. CCLD’s investigation involved an unannounced facility tour and welfare check on residents in care. The Department also reviewed pertinent care, medical, hospital, and hospice records, and interviewed relevant staff and outside sources.

[CONTINUED ON LIC 9099-C, 1 of 3]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 08-AS-20211101091549

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: GROSSMONT GARDENS	FACILITY NUMBER: 374604060
	VISIT DATE: 04/11/2024

NARRATIVE

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[CONTINUED FROM LIC 9099]

Per the Pre-Admission Appraisal (i.e., “ESL Level of Care Chart Detail”) which Licensee authored on R1 on 10/17/2021, Licensee determined R1 was wheelchair-bound, had total loss of use of their legs, required a Hoyer-Lift machine with 2-person assist to transfer, and needed “turning and positioning” “4x daily” in bed to prevent skin break down. R1 hospice agency’s records reiterated that R1 had “total loss of function” in their legs, was “bedbound,” and required “full assistance with repositioning.” Licensee accepted R1 for move-in on 10/18/2021, with constructive knowledge and understanding that R1 fully relied on its staff for turning/repositioning in bed.

However, hospice records, hospital records, facility records, and interviews of both outside sources and facility managers aligned, to show: On 10/27/2021, Licensee held a care conference with R1’s hospice agency staff and R1’s responsible person to announce that routinely turning/repositioning R1 in bed was not something that facility staff did for R1 since they moved in, and also not something facility staff could do for R1 going forward. Soon after this meeting (the same day), R1’s hospice agency and responsible person arranged for R1 to be sent to a hospital emergency room for treatment of multiple pressure injuries.

In R1’s LIC602 Physician’s Report (dated 10/15/2021, which was before move-in), there was no mention of skin breakdown anywhere on R1’s body. However, assessment notes and nursing notes from Licensee’s staff showed that when R1 moved-in to the facility on 10/18/2021, R1 had preexisting redness on their coccyx (i.e., tailbone) area. R1’s hospice agency also corroborated that there was redness on R1’s coccyx which was “dry.” R1’s coccyx skin was closed at that time; there was no identification of redness and/or skin breakdown on any other area of R1’s body.

According to dated, handwritten progress notes from the facility’s own nurses: By 10/21/2021, R1 had new pressure injuries to their left hip and right upper back (in addition to their existing coccyx injury). Facility staff received and logged doctor’s orders for dressing changes and instructions to turn and reposition R1’s body every two hours and to “float” R1 heels so that they don’t touch the mattress when R1 is laying.

[CONTINUED ON LIC 9099-C, 2 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20211101091549

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: GROSSMONT GARDENS	FACILITY NUMBER: 374604060
	VISIT DATE: 04/11/2024

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 3]

Per hospice agency electronic progress notes: By 10/23/2021, R1 had an “unstageable” pressure injury on their coccyx that was 1.5 cm long by 1.5 cm wide, with “serosanguineous” (i.e., serum and blood) drainage. R1 also had an “unstageable” pressure injury on their right upper back that was 3 cm long by 1 cm wide with “serosanguineous” drainage, plus an “unstageable” pressure injury on their left lower back that was 1 cm long by 2 cm wide with “serosanguineous” drainage. A hospice nurse visited R1 that same day, writing that they found R1 flat on their back in bed (not rotated, as required). The pillows provided to facility staff to prop up and reposition R1 were instead on the ground.

Hospice agency electronic progress notes further showed: By 10/27/2021, R1’s coccyx pressure injury had expanded to 2 cm long by 2 cm wide, with “purulent” (i.e., containing pus) drainage. The pressure injury on R1’s right upper back was now 2.5 cm long by 2 cm wide, with “purulent” drainage. R1 also now had an “unstageable” ulcer on their left hip that was 1 cm long by 2 cm wide with no drainage, plus a “Stage 1” (i.e., redness, closed skin) pressure injury on their left heel which was 3 cm by 3 cm, and “blisters” on their right heel which were 3 cm by 3 cm.

According to hospital records, R1 was taken to the emergency room on 10/27/2024 because they had a “wound on coccyx and staff at the facility are unable to care for it.” Hospital records showed R1’s “sacral / coccygeal” pressure injury was 2.5 cm long by 3 cm wide, “unstageable,” and infected (but not septic), for which R1 received intravenous antibiotics. Hospital staff also assessed R1’s left and right heels as both “Stage 1.”

R1 discharged from the hospital to a different assisted living facility on 10/30/2021 (instead of returning to Grossmont Gardens). Per hospice agency records: On 11/05/2021, R1 had an “unstageable sacral pressure ulcer 3 X 2 X 0.5 cms,” an “unstageable upper back pressure ulcer 3 X 2 X 0.5 cms” (a diagram showed it was over the right shoulder blade), and “Right and left heel stage 1, 2 X 2 cms, 2 X 2 cms” injuries. However, staff at the new facility followed instructions to routinely reposition R1. By 12/01/2021, R1’s back and heels were completely healed; only R1’s sacral wound remained. According to their official Death Certificate, R1 passed away on 12/08/2021 due to “respiratory failure,” secondary only to “hepatocellular carcinoma.” (Neither skin breakdown nor infection were contributing factors to R1’s death.) [CONTINUED ON LIC 9099-C, 3 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20211101091549

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: GROSSMONT GARDENS	FACILITY NUMBER: 374604060
	VISIT DATE: 04/11/2024

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 2 of 3]

Based on interviews and records, a preponderance of evidence exists to show that Licensee’s staff neglected to turn/reposition R1 in bed, which contributed to R1’s sacral injury worsening and to R1 developing pressure injuries in other areas of their body. Therefore, the allegation is Substantiated. A deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 9099-D page). The Department determined that the violation resulted in injury to a resident in care. An immediate Civil Penalty of $500.00 is therefore charged (refer to the LIC421-IM page). Per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division.

Since the facility had closed and ceased operations as of the date of deficiency issuance, no Plan of Correction was formed with the Licensee. A copy of this report, the LIC 9099-D, the LIC421-IM, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee via USPS certified mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20211101091549

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: GROSSMONT GARDENS	FACILITY NUMBER: 374604060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2024 Section Cited CCR 87633(d)	1 2 3 4 5 6 7	87633 Hospice Care of Terminally Ill Residents: “(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	As of the date of deficiency issuance, R1 had already passed away and the facility had closed and ceased operations. Therefore, no Plan of Correction was formed with the Licensee.
	8 9 10 11 12 13 14	Based on records and interviews, Licensee did not meet the care needs of 1 of 200 residents (R1), who was also under hospice care. This posed an immediate health risk to persons in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

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