Facility Evaluation Report

This report has been amended to correct deficiencies from type B to type A.

Licensing Program Analysts (LPA), Valeria Conway, conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240311081755). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Administrator, David Aguiniga and explained the reason for the visit.

During the Department’s investigation of complaint, the following deficiencies were observed:

Resident #1 (R1s) care with Star World Home Health began on 01/30/2024, the home health nurse reported a Stage 2 pressure injury on R1’s coccyx measuring 0.3x0.2x0.2cm. A Physician’s Order from Dr. David Wong recommended a Skilled Nursing visit one time a week for 3 weeks. Dr. Wong’s order stated the following, “Skilled Nurse to perform/demonstrate and instruct patient/caregiver regarding coccyx pressure ulcer as follows: cleanse with wound cleanser, pat dry, apply triad paste and leave open to air daily. Patient caregiver may perform treatment during non-Skilled Nurse visit days. Coccyx pressure ulcer will be healed with current treatment by 4 weeks. Wound will remain free from signs and symptoms of infection, or complications during the treatment period”. The administrator was made aware of and agreed to the treatment plan. The staff were not skilled professionals qualified to perform the treatment. R1’s pressure injury became progressively worse and by 03/01/2024, R1 was diagnosed with an unstageable pressure injury.