Allegation “Neglect/lack of care led to Resident #1 (R1) sustaining multiple pressure injuries:”

The complaint alleges that R1, who is a former resident of Silverado Senior Living Calabasas, sustained at least three (3) stage three pressure injuries while in care at the facility. Record review revealed that R1 moved into the facility on 12/23/2020. R1’s diagnoses listed on the physician’s report dated 12/26/2022 included but were not limited to: dementia, type 1 diabetes and hypertension. R1 was noted to be non-ambulatory and required assistance with transfers. At that time, R1’s physician indicated R1 had no history of skin condition or breakdown. Facility care notes indicated that R1 had a “boil” on their right buttocks noted on 04/20/2023. Home health certification and plan of care with a certification period of 05/24/2023 – 07/22/2023 with provider listed as Sunset Healthcare, Inc. indicated a diagnosis of “pressure ulcer of right buttock.” Plan of care included “stage 3 pressure ulcer wound care and status until further orders from MD.” Review of documents provided revealed the facility reached out to R1’s family member requesting a change in Home Health provider on 07/24/2023. Initial consult with Wound Masters occurred on 08/07/2023 which indicates “per caregiver, [R1] previously had an abscess at that location that self-ruptured.” Site of the wound was listed as right posterior thigh/leg. It is unclear when R1 sustained this pressure injury, as facility charting is incomplete, with entry on 07/28/2023 indicating “home health eval for wound care to right medial buttocks wound,” however, no mention of the posterior thigh wound and no additional entries were made until 08/11/2023. It also appears that no home health was contracted or provided from 07/23/2023 to 08/07/2023. Interview with medical professional revealed that due to observed fat layer exposed, the thigh wound was categorized as a stage 3 wound. A third wound was assessed on 10/02/2023 on R1’s right gluteal fold, buttock. This wound was listed as a “pressure ulcer stage 3.” Wounds treated by Wound Masters were recorded as resolved on 01/22/2024. Interview with facility staff revealed the resident was repositioned every 2 hours, however, LPA did not observe any documentation of repositioning. Staff stated that they were unaware of any pressure injuries on R1 and staff referred to R1’s documented pressure injuries as “boils.” Even when IB investigator showed staff home health notes indicating R1’s wounds were labeled “pressure ulcer” or “pressure injury,” staff stated they had “no idea” why they had documented these wounds as boils or blisters. Although R1 had no history of skin breakdown prior, R1 sustained 3 (three) documented stage three wounds while in care at the facility. Based on information

Report Continued on LIC 9099-C

Allegation “Facility did not seek timely medical care for R1 resulting in the facility retaining a resident with a prohibited health condition:”

The complaint alleges that facility staff did not seek timely medical treatment for R1’s wounds. As outlined above, the facility staff noted a “boil” on R1’s right buttock on 04/20/2023, however, home health services were not contracted to provide service for the stage 3 wound until 05/24/2023, over a month after the skin abnormality was identified. According to R1’s family member, they were not notified of the pressure injury until 05/31/2023. The Regional Office received no written notification of any of R1’s 3 (three) pressure injuries. Also, as outlined above, R1 did not have home health services to care for R1’s wound(s) from 07/23/2023 until 08/07/2023. During the intake assessment, Wound Masters identified a second wound. It is unclear when the second wound occurred, as the facility’s care notes were incomplete. Although the facility did assist in contracting home health services for R1’s wounds, there was a delay in beginning services and a lapse in coverage between providers. Additionally, stage 3 and stage 4 wounds are considered prohibited health conditions under Title 22 regulations and residents with prohibited health conditions cannot be retained at the level of care Silverado is licensed to provide as a Residential Care Facility for the Elderly (RCFE.) Under the facility’s approved hospice waiver, residents that are contracted for third-party hospice services can be retained with prohibited health conditions. However, record review and interview revealed that R1 was not admitted to hospice care until 10/01/2024, well beyond the time R1 had the 3 (three) identified wounds. Additionally, record review revealed R1’s physician’s report dated 12/26/2022 indicated R1 lacked the capacity to bathe, dress/groom or feed themselves, nor could R1 care for their own toileting needs or manage their own cash resources. Therefore, according to R1’s physician, R1 required full ADL (activities of daily living) care, which is also a prohibited health condition under Title 22 regulations. LPA reviewed documents sent to the Woodland Hills Regional Office and did not find an exception request to retain R1 with either prohibited health condition. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore the allegation “facility did not seek timely medical care for R1 resulting in the facility retaining a resident with a prohibited health condition,” is deemed SUBSTANTIATED at this time.

Report Continued on LIC 9099-C

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.