Complaint Investigation Report

Regarding the allegation #1: Resident sustained pressure ulcers while in care

It was alleged that the Resident (R1) was diagnosed with stage IV pressure injuries on the left and right buttocks while living at the facility. On 6/25/2020 and 9/3/2020, investigator conducted interviews with administrator and staff members S1-S5 regarding R1’s pressure injuries. On 6/25/2020, S1-S5 stated resident was placed on incontinent care and was found with 2 small red sores on the lower left and right buttocks. Investigator reviewed the records and notes instructed staff to change R1 every 2 hours. On 9/3/2020, interview conducted with witness (W1) confirmed R1 to wear adult diapers on 6/25/2020. On 10/13/2020, Investigator conducted an interview with R1, and resident was unable to recall any details. Interviews conducted with S1-S5, confirmed with the Investigator R1 diapers was changed every 2 hours. Kaiser Medical records revealed on 6/27/2020, R1 had a stage 2 pressure injuries ulcer on the bilateral gluteus. On 7/9/2020 Kaiser noted a stage 3 pressure injuries on the left and right buttocks. Based on interviews and records review, R1 did not sustain a stage 3 or 4 pressure injuries while living at the facility. The above allegation is found to be unsubstantiated.

Regarding Allegation: Staff did not change residents soiled diaper in a timely manner

It was alleged that resident was sitting in diapers for an extended period. On 10/5/2020, LPA conducted interviews with Residents (R1-R6). During interviews conducted, 6 residents stated they have no concerns with their diapers being change. Residents stated staff will change them every 2-3 hours and will call staff if needed to be change earlier and staff will assist. LPA conducted interviews with the Brad Dehann- Administrator, Sidonia Cordis- Resident Care Director and staff members S1-S7 regarding the above allegation. Administrator, Resident Care Director and S1-S7, stated residents that are incontinent are change every 2-3 hours. LPA reviewed R1’s Changing Log and dates that stated R1 was changed every 2 hours and

It was alleged that resident was evicted unlawful. Interviews conducted with the Administrator, Resident Care Director and residents S1-S7. On 10/5/2020 Administrator stated Resident Care Director stated R1 had went to the hospital on 6/27/2020. Administrator and Resident Care Director stated resident was able to come back to the facility once R was released from the hospital. R1 was unable to return to facility due to needing higher level of care. Residents Interviews conducted with S1-S7, did not hear of any unlawful eviction with any residents. LPA reviewed records and R1 was in the hospital and transferred to a skill nursing facility on 7/15/23. Resident still had belongings in the facility with the anticipation of returning but resident was unable to return to the facility. Resident was not evicted from the facility.

Continuation LIC 9099 is on the next page.