Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings regarding allegations listed above. LPA met with Administrators Anna and Alena Polyakova during today's inspection.

On May 4, 2023, the Department concluded a complaint investigation. During the course of the complaint investigation, it was learned that facility staff did not seek timely medical attention for R1 regarding pressure injuries. Interviews indicated staff were aware R1 had several pressure injuries that were worsening and resident had an overall decline. Resident had been less mobile over the last 3-4 days prior to being sent to hospital, staying in bed most of the time and was not eating or drinking for multiple days. Once admitted to the hospital on April 7, 2020 , R1 was diagnosed with a stage 3 pressure injury to their right sacral area resulting in hospitalization. Facility staff stated they reached out to R1’s primary care physician on April 6, 2020. Staff claimed they noticed a skin breakdown worsening with an apparent odor, and waited for resident’s PCP to call back instead of bringing R1 to the hospital right away. Based on facility staff’s acknowledged observations of R1’s worsening condition, facility staff failed to provide care and supervision and delayed timely medical treatment that resulted in hospitalization for Unstageable, Stage 3 and Deep Tissue Injury. Deficiencies are being cited for violating the following California Code of Regulations (CCR) Title 22:

87465 Incidental Medical and Dental Care (g) 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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).