Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite additional deficiencies which were identified during a separate complaint investigation. LPA was welcomed by and identified himself to Caregiver Jovina Franco. LPA then met with and discussed the purpose of the visit with Administrator Jushua "Justin" Mendoza, who arrived shortly after.

According to facility care and hospice records, and corroborated by staff and outside source interviews, Resident #1 (R1) had no pressure injuries or areas of open skin when they first moved into Solaris 36 in January 2020. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] R1 was initially under hospice care for lymphoma but they discharged from hospice services on 04/02/2020. Starting 04/03/2020, R1 was under the concurrent care of an outside home health (HH) agency.

In their individual interviews: Staff #1 (S1) said sometime in April 2020, a closed mass on R1’s sacrum had opened-up, become “darker and softer to the touch,” “bluish” or “purplish,” had foul odor, and wept “yellowish” discharge. Staff #2 (S2) said a “fist”-sized area on R1’s sacrum opened-up, went from “normal color” to “red,” wept blood and puss, and smelled badly. S2 could not remember approximately when this started. Manager Staff #3 (S3) said their direct reports summoned them to personally look at R1’s sacrum on 04/01/2020, which had opened-up with foul odor and discharge. S1 said that R1’s responsible person (RP) and their HH agency [where R1’s assigned physician (PCP) was based] were timely informed by S3 of the skin breakdown on R1’s sacrum. However, interview of S3 showed they did not personally notify those parties of the problem. Rather, S3 was under the impression that S1 had completed such communication to RP and HH/PCP.