Complaint Investigation Report

documents, physician’s documents and wound care records. LPA then reviewed all information obtained by Investigator Seng. The following was then determined:

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