Complaint Investigation Report

During the investigation process, it was indicated that a resident (Resident 1) was having difficulty with care to his infected feet. The resident’s feet appeared to have dry skin, were infected with what appeared to be yellow pus under several toenails and his feet were discolored. On 03/06/23 LPA Gurriere took photos of the resident’s feet which appeared to be in extremely poor condition.

On 03/03/23 the facility staff contacted emergency services in an effort to have the resident seek medical treatment at the hospital. When the resident arrived at the hospital, it was reported that the resident refused care and was sent back to the facility without treatment.

On 03/06/23, Donna Gurriere, Licensing Program Analyst met with the resident to discuss his medical treatment. LPA Gurriere asked the resident how he was doing with his feet and the resident stated that his feet were “Fine.” LPA Gurriere asked the resident if she could look at his feet and the resident allowed LPA Gurriere to see his feet.

The resident refused care at the hospital, the resident could not get into see his doctor until May 2023 and the resident was not opened to home health treatment or hospice care. The resident was not getting any care at the facility to assist in his infected feet and toes. On 03/08/23, it was reported by the administrator that the resident was opened to the hospice agency to address the resident’s infected feet.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.