Complaint Investigation Report

R1 was treated for infection and wounds, and a total of nine maggots were removed from R1’s right ankle. According to interviews and record reviews, R1’s wounds became worse over time. Additionally, witness interviews revealed R1’s bandages on 9-7-23 were described as "old, dingy, and covered in blood and puss", which indicated bandages were not changed in accordance with R1s care plan. Moreover, interviews revealed R1 was only bathed once or twice per week which is counter to R1’s care plan stating R1 was to be bathed at least every other day. R1 was hospitalized from 9-7-23 to 9-12-23. Record reviews revealed that the maggot infestation appeared chronic “and if daily bandage changes were being performed this would have been noticed at least the day before” hospitalization. Based on record reviews and interviews, it is determined that facility staff did not properly care for R1 which resulted in R1 being hospitalized for cellulitis worsening wounds, and maggot infestation. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff did not meet resident hygiene needs. The Department conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was determined that R1 was bathed once or twice per week. R1 had a care plan in place which stated R1 was to be bathed at least every other day. Additionally, it was determined through record review and interviews that R1 was treated for cellulitis and maggot infestation during a hospitalization period between 9-7-23 and 9-12-23 due to bandages not properly changed and legs not properly bathed and cleaned. Facility’s care log sheet for personal hygiene and grooming indicates various hygiene performed consistently for R1, however, does not indicate bathing of R1’s legs. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued under Title 22, Division 6 and noted on LIC 9099D. An immediate civil penalty in the amount of $500 is issued in addition to citation due to injury resulting from the violation. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1548(f)(1)(A). An exit interview was conducted with Lynn Caoli and a copy of this report was left with Lynn. LIC 811 provided. Appeal rights provided.