complaint·December 1, 2021

On 05/19/21, LPA Tao obtained copies of Staff and Residents rosters, toured the physical plant and did not observe that facility staff were not assisting with residents with incontinent care and LPA Tao did not observe any unusual odors in the facility. During the investigation, LPA Tao interviewed with Resident#2-#12 and Staff#2-#5 and Staff#11; reviewed R#1 medical records and R#1 facility file. In addition, on 08/22/19, LPA Razo conducted interviews with staff #6-#10. In regard of allegation: Resident sustained multiple pressure injuries due to neglect. The investigation revealed the following. The allegation was alleged that R#1 received extensive skin damage due to moisture and had multiple pressure injuries. Former Administrator Pat Redner denied the allegations. Per resident interviews, ten (10) out of twelve (12) residents stated they were not aware of a resident who sustained pressure injuries due to neglect. One (1) of twelve (12) residents was unable to answer LPA's questions. LPA Tao was unsuccessful in attempts to interview R#1, who has been relocated and lost contact. Interviews with eleven (11) out of eleven (11) staff indicated that staff denied knowledge that a resident sustained multiple pressure injuries due to neglect. Interviews with staff revealed that staff provided care to R#1 by repositioning/turning R#1 every two hours and elevated R#1's feet while R#1 was in chair and/or bed. During a site visit on 05/19/21, LPA Tao observed staff would assist residents who required assistance with repositioning as needed. The investigation revealed the following, R#1 was admitted to the facility on 01/21/19, upon admission to the facility, R#1 had redness to inner buttock, left and right legs. (-Continued in LIC 9099 C-) From date of admission through 05/04/19, staff assisted R#1 with changes of R#1 adult briefs due to incontinence care and repositioned R#1 as needed. There was no evidence to support that staff left R#1 skin moist or wet. Review of R#1's records; including medical records revealed that R#1 was admitted to Arcadia Methodist Hospital on 05/05/19 for general weakness and not feeling well. Upon admission to the hospital, it was noted by medical staff that R#1 had redness on resident's inner buttocks, left and right legs. On 05/06/19, the hospital’s physician ordered a test to determine and assess if R#1’s wounds were due to artery blockage since the wounds appeared to be arterial in nature. The results of the test were received on 05/06/19, which indicated R#1 wounds were caused by poor blood circulation or artery blockage and not by moisture on the skin. The investigation did not reveal that staff neglected R#1, resulting in R#1 sustaining wounds. In regard of allegation: Staff left resident in soiled diapers for an extended period. The investigation revealed the following. Per the complaint, it was alleged that Resident #1 was left in soiled diapers for an extended period. Administrator denied the allegation. Per resident interviews, seven (7) out of twelve (12) residents who use adult briefs stated staff did not leave them in soiled diaper for an extended period Three (3) out of twelve (12) residents who did not use adult briefs stated they were not aware of residents who used adult briefs complaining of staff leaving residents in soiled diaper for an extended period. One (1) of twelve (12) residents was unable to answer LPAs questions. LPA Tao was unsuccessful in attempts to interview R#1, since resident has been relocated and lost contact resident. (-Continued in LIC 9099 C-) Interviews with eleven (11) of eleven (11) staff revealed that staff would change residents' diapers in a timely manner. Per staff interviews, staff denied residents were being left in soiled diapers for an extended period and changed resident’s adult briefs every two hours or as needed. Review of resident record regarding resident who were incontinent and needed assistance with changing of adult briefs, revealed that staff changes resident’s adult briefs every two hours. Per LPA Razo's and LPA Tao’s observations during site visits conducted on 10/19/19 and 05/19/21, LPAs did not observe any foul odors or smell of urine at the facility. The investigation did not reveal any evidence to support that staff left residents in soiled diapers for an extended period. Therefore, there was insufficient evidence to corroborate with the allegation. Based on the information obtained during the investigation, interviews with staff, residents, review of resident file/medical records and LPAs' observation, the investigation did not reveal any evidence to support the following allegations: Resident sustained multiple pressure injuries due to neglect and Staff left resident in soiled diapers for an extended period. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator, Pamela Parsons and Licensee, Julie Chirikian. Findings were discussed. A copy this report was provided to Administrator at time of visit.