Complaint Investigation Report
Resident's R2 and R3 only heard about late response time for diaper changes. Said they don't use diapers.
Home Health Nurse stated that caregivers assisted her with Resident R1 regarding incontinence care.
Stated they came within 5 minutes. Said it is Stage 2 wound and it is on and off with healing, Said they were not getting worse and wound was not declining.
Wound specialist stated that there was no moisture from urine and no redness and this shows no neglect by facility.
Staff stated that they do an hourly resident check and document it. Stated Resident R1 leaves the facility frequently and sometimes is not there when changes are to be done.
Resident One Hour Check 04/24/25 noted from 11 PM to 12 AM Resident R1 was outside in parking lot and was put in the bedroom.
On 05/07/25 changed Resident R1 and put her to bed.
On 05/16/25 4:00 AM staff helped give assistance to Resident R1 who was being uncooperative.
05/19/25 1:00 AM to 2:00 AM staff went to parking then to bedroom with Resident R1 and changed the diaper.
Based on record review and interviews conducted, the findings indicate, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
In regards to the allegation Staff do not prevent resident from developing pressure injuries while in care, based on interviews conducted and information gathered Home Health Nurse stated that she felt wounds did not decline and felt facility was providing good care.
Wound specialist stated that there was no moisture from urine and no redness and this shows no neglect by facility.
Staff stated that they do an hourly resident check and document it. Stated Resident R1 leaves the facility frequently and sometimes is not there when changes are to be done.
Hourly checks done on 05/07/25 changed Resident R1 and put her to bed.
On 05/16/25 4:00 AM helped give assistance to Resident R1 who was being uncooperative.
05/19/25 1:00 AM to 2:00 AM staff went to parking then to bedroom and changed the diaper.
Resident's 2-7 stated that they do not have any pressure sores and staff assist others in a timely manner.
Based on record review and interviews conducted, the findings indicate, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction