Complaint Investigation Report

Review of home health records (11/19/22) showed that when R1 was released from Kaiser Permanente on 11/19/2022 before returning to the assisted living side of Bellaken Garden, the home health nurse noted that R1 needed skilled nursing care.

While in the assisted living side of Bellaken Garden R1's pressure injuries progressed from stage 3 to unstageable. R1 stayed in assisted living of Bellaken Garden for two weeks before she was transferred to the skilled nursing side of Bellaken Garden due to waiting on doctor approval. R1 continued to receive home health nurse services until her transfer to skilled nursing.

The Department has investigated the complaint alleging a resident sustained an ulcer in care at the facility due to staff neglect. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

Exit interview conducted, a copy of this report provided.