Complaint Investigation Report

Regarding Allegation #1 : this investigation revealed that Resident #1 had been transferred on 08/21/20 from (then) Le Bleu Chateau (#198603136) due to a decline in the resident's health condition. Resident #1 was hospitalized on 12/09/20 as a result of testing positive for COVID-19. Resident #1 was later transferred to a skilled-nursing facility (SNF) for twenty (20) days before returning to Le Bleu Chateau Gold (#198603137) on 12/24/20. Upon Resident #1's return from the skilled-nursing facility, Staff #2 (S2: Ma Nieva, Med Tech - A.M.) noticed redness to Resident #1's bottom (coccyx) and informed Resident #1's family member and requested home health. Kaiser Home Health Nurse followed up with Resident #1 after five (5) days. Staff #3 (S3: Ging Madrigal , Med Tech - P.M.) and Staff #7 (S7: Lien Seesee, Activities Director) met with the Kaiser Home Health Nurse who observed Resident #1's wound on 12/30/20 at 4:30 p.m. to only be slight redness to resident's bottom (coccyx). Interviews conducted corroborated that Kaiser Permanente Home Health Nurse did not leave notes and there were no other visits regarding Resident #1's wound care. Resident #1 passed away due to complications of COVID-19 based on the Death Report, dated 01/02/21.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident sustained a pressure injury while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2 : this investigation revealed that Resident #1 was hospitalized for COVID-19 and no hospital records or discharge paperwork were made available to the facility for reporting Resident #1's diagnosis upon discharge from Kaiser Permanent Hospital on 12/09/20. Resident #1 was discharged to a skilled-nursing facility (SNF) for twenty (20) days before returning to Le Bleu Chateau Gold (#198603137) on 12/24/20. Upon Resident #1's return to the facility on 12/24/20, the resident was still positive for COVID-19. Resident #1 had been receiving home health care through Kaiser Permanente until R1's passing on 01/02/21.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident not properly hydrated while in care is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #5 (S5: Silvia Valdez, Community Ambassador, Marketing Director)