Complaint Investigation Report, 10/03/2025 — Oakmont of Silver Creek, San Jose CA

Staff were interviewed on 08/07/25 and 08/08/25.

Staff 1 (S1) stated that on 07/10/25, while attending to R1s needs, S1 and another staff (S2), noticed a purple bruise on R1s right leg shin and notified the medication technician (MedTech) (S3) on-duty. On 07/12/25, while getting R1 ready for the morning, S2 noticed nail marks on R1 left and right arms and hands. S1 stated the nail marks were not there on 07/11/25. S2 then stated to S1 that R1s injury on the right shin “looks really bad.” S1 stated that he/she does not know if S3 or other MedTech reported the injuries to R1s responsible party (RP). S1 also stated that he/she does not know if R1 was taken to his/her physician to be checked. S1 stated that he/she does not know how the injury was missed, because S1 reported the injury right away.

Staff 2 (S2) stated that he/she does not document anything during his/her shift. S2 stated that he/she reports verbally any skin issues to MedTech on-duty. On 07/12/25, S2 stated that staff 4 (S4) came to assist and cleaned R1s left and right arm injuries. S2 proceeded to remove R1s pant and sock and discovered that R1s injury on the right shin has worsened. S2 stated the injury was very red, oozing water like gangrene and approximately the size of an apple watch face (42mm). S2 stated “the flesh was growing.” S1 and S2 put a bandage on the injury. S2 did not know if S3 documented the injuries when it was reported.

Staff 3 (S3) stated that on 07/12/25, he/she notified his/her supervisor (S7) via text message of R1s arm and shin injury and noted the injuries on the whiteboard but S3 did not report electronically. S3 informed the PM MedTech of R1s injuries to the arms and shin. On 07/18/25, S3 observed the arm injuries were healing, but the right leg shin injury was inflamed and had a pungent discharge.

Staff 5 (S5) stated on 07/15/25, nothing was reported regarding R1s injuries and he/she was not aware that R1 has injuries. On 07/17/25, another staff (S8) notified S5 of R1s injuries. S5 stated he/she was very busy and could not attend to R1s injury right away. S5 stated that he/she reported R1s injury to R1s responsible party (RP) when RP came to visit R1 on 07/17/25. S5 stated that on 07/12/25, S3 reported to R1s physician about the injury, but did not document and did not notify RP. S5 stated that the facility has a skin check log and staff are supposed to complete the log and MedTech are supposed to assess skin issues.