Complaint Investigation Report

On 03/12/2024, from 9:10 a.m. to 4:15 p.m., LPAs Valeria Conway and Zabel Chochian conducted an unannounced 10-day complaint visit. At 10:00 a.m., the LPAs conducted a physical plant tour of the facility with the Assistant Administrator to ensure there were no health and safety hazards. From 11:05 a.m. to 1:15 p.m., the LPAs conducted records review including but not limited to resident records, facility internal records and obtained copies of pertinent documents relevant to the investigation.

On 04/14/2024, from approximately 4:31 p.m. to 5:13 p.m., Investigator Seng conducted interviews with R1’s Resident Representative and Kaiser Permanente Clinical Social Worker; on 05/16/2024, from approximately 8:47 a.m. to 10:58 a.m., with the facility Assistant Administrator, caregivers, and residents; on 06/11/2024, from approximately 4:50 p.m. to 5:54 p.m., with caregiver and an attempted interview with R1 (R1 unable to be interviewed due to mental condition of dementia and non-verbal); and on 06/12/2024, at approximately 2:01 p.m., with Star World Home Health nurse. In addition, the investigator obtained and reviewed medical records from Kaiser Permanente, Astoria Nursing and Rehabilitation Center, Grand Valley Health Care Center, and Star World Home Health, photos of R1’s pressure injury, and facility file documents related to the investigation.

According to medical records reviewed, R1 was initially admitted to the Grand Valley Health Care Center (GVHCC) on 12/23/2022 for a left femoral neck fracture (hip fracture). On 01/25/2024, R1 was discharged and admitted to the Glen Park at Valley Village facility. The discharge paperwork from GVHCC did not indicate a pressure injury. However, GVHCC records reviewed indicated that on 01/11/2024, R1’s Patient Care Plan notated R1 had a pressure injury on R1 Sacro coccyx which was listed as a Stage 2. The goal was to ensure the sore was healed within 90 days. The Assistant Administrator stated R1 had no pressure injuries upon admission to the facility, however, it is unknown if a body check was completed. During R1’s file review it was noted R1’s Head to Toe Assessment form was not filled out and left blank, both in the file review and when the investigator requested to view the documents in person.