Complaint Investigation Report

LPA Jeffries conducted an interview with Facility Administrator and Licensee, Amelita I. Aquino, who stated that R1’s complete resident file was in a green folder and given to the Emergency Medical Technicians (EMTs) when they transported R1 to the hospital on 11/04/2024. Only documentation Administrator had for R1 was R1’s LIC602 (Physician Report), Skilled Nursing Visit Report (SKR) dated 10/29/2024 from Central Coast Home Health Inc. and R1’s Centrally Stored Medication Record (CSMR). On 11/19/2024 LPA Jeffries received an email from Administrator Licensee that R1’s file was lost. On 11/05/2024, LPA Jeffries reviewed documentation of R1’s Physicians Report (LIC602) signed and dated 01/26/2024 which indicated R1 having a primary diagnose of Chronic venous stasis ulcers to BLE's" [medical condition where open sores (ulcers) develop on the lower extremities (BLE's - below the knee) due to poor blood flow in the leg veins], additionally a history of skin break down, also requiring help in Activities of Daily Living (ADL’s) in bathing, grooming, and toileting needs. Both staff stated R1 could walk around in the backyard for exercise, and regularly slept in a recliner. Staff all indicated R1 was able to reposition themselves in the recliner, and transfer themselves from the walker to and from the recliner, and to and from the shower chair. LPA reviewed SKR dated 10/29/2024, indicating a Licensed Skilled Professional attended and dressed two wounds (stage 2) located on the left and right side of R1’s buttock (same area as Sacrum). On 11/18/2024, LPA Jeffries interviewed direct care staff 1 (S1) who stated that R1 had regularly schedule showers every other day. S1 stated that on 11/03/2024, R1 was provided a sponge bath due to mobility issues. S1 stated that every other day prior to 11/03/2024, R1 was provided full assistance with a full shower and bathing routine. S1 stated that R1 had chronic skin conditions that required full showering routine due to scalp and skin condition. S1 stated that there was a dime size wound on R1’s lower back that was treated by Home Health and facility staff twice per week. On 11/05/2024, interviews with S2 and administrator, both stated that R1 would have full shower and bathing assistance every other day, as well as wound care by Central Coast Home Health twice per week. On 11/05/2024 LPA Jeffries attempted to interview 4 of 4 residents at the facility, however no resident was able to complete interview. LPA noted that 4 of 4 residents were clean, free of odors and appeared to be well groomed. LPA attempted to interview R1’s responsible party, but LPA’s calls were not returned. LPA attempted to obtain photographs of R1’s condition from W1, but the photographs were never provided to LPA. LPA attempted to interview home health personnel who visited R1, but personnel declined LPAs requests for interview. LPA also reached out to the licensee for direct phone numbers and names of home health personnel, but licensee was unable to provide the documents.