complaint·May 16, 2025

***CONTINUE FROM 9099*** The facility reviewed video surveillance showing only staff entered R1’s room during the time frame of 6:30 AM to 12:00 PM. The internal investigation concluded the injury may have been caused by either R1's long fingernails or accidental contact with hospital bed rails during repositioning. A corresponding Unusual Incident Report for the injury was submitted to CCL. LPA interviewed W1 who stated that when she visited R1 on 08/24/2024 and observed what appeared to be a full black eye, not a minor bruise. W1 took photographs and contacted facility staff, but no additional explanation was provided at that time. W1 also contacted Kaiser, which led to a welfare check by the Alameda County Sheriff’s Office on 08/24/2024. It was reported that the officer interviewed R1 and staff but did not report any findings. W1 stated in written communication that no incident report was initially shared with them and that the description of the injury appeared inconsistent with what they observed in person. Allegation : Facility staff did not seek medical attention for resident in care LPA interviewed S1-S5 who confirmed that the resident’s physician was notified the same day via faxed. There is no indication in the facility's records that an in-person physician visit was ordered or conducted. Facility records indicate that the resident was assessed for additional injuries, found to be stable, and showed no signs of pain or discomfort. The resident’s care plan was reassessed, and follow-up action was taken, including changes to repositioning protocol and equipment. LPA interviewed W1 who reported that after observing the injury on 08/24/2024, they contacted Kaiser to request medical evaluation for R1 but W1 did not want R1 to go to Kaiser. W1 worried that if R1 went to the hospital she would be exposed to Covid. Kaiser requested Alameda County Sheriff’s Department to perform a welfare check. Documentation submitted by W1 includes photographs of R1’s injury and email communications expressing concern that no physical medical evaluation had occurred and that no clear explanation of the injury was available. Interviews with facility staff revealed that R1 received proper medical evaluation for her injury. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** This agency has investigated the above allegations. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.