Complaint Investigation Report
Licensing Program Analyst (LPA) Tihesha Smith and Naira Margaryan conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation on 05/23/2024. Staff denied being neglectful in R1’s care. Interviews revealed that R1 was admitted to the facility with red blisters all over their body. Resident was admitted to the facility with assigned hospice services. Although the Administrator was informed that the red blisters on R1’s body are not infected and will not transfer to others, the Administrator sent R1 to the hospital. R1 returned to the facility within 2 hours per discharge records and R1 had a chronic condition: “adult rush” requiring daily treatment. The Administrator stated that R1 was in the facility for one (1) week and within that week due to discomfort, R1 went to the hospital 3 times. On 03/28/23, R’s condition was discussed with the discharge nurse at the hospital and the decision was made to transfer R1 to a Skilled Nursing Facility.
A review of the facility records verified the information revealed by the staff. There was no information or evidence available during this investigation to conclude that R1 sustained multiple pressure injuries due to neglect. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time.
Staff did not have accurate records for resident.
It was alleged that staff did not have accurate records for residents. Interview with the administrator revealed
that she had all required documents for each resident. A review of the records including R1’s facility file, revealed that although the files were not organized, all required documents were present in folders designated for each resident. Due to no information available to support the allegation, therefore, based on observation and record review the allegation is UNSUBSTANTIATED at this time.
Staff did not abide to the admission agreement
It was alleged that credible witness observed lack of appropriate admission and discharge documentation.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction