complaint·June 12, 2025

This complaint was referred to the California Department of Social Services Investigation Bureau for an investigation on 09/05/24. As a part of the investigation, the department subpoenaed medical records, including imaging records and other writings, referring, or relating to the medical history, mental or physical condition, diagnoses, and/or treatment from Kaiser Permanente for resident (R1). Additionally, the department requested medical records from All Care Home Health, Comcare Home Health, and Omnicare Home Health agencies. The department interviewed staff (S1-S2), resident (R2), and witnesses (W1-W4). The investigation revealed the following: Allegation#1 - Facility staff neglect resulted in resident developing stage 4 pressure injuries The details of the complaint alleged that the resident (R1) while under the care and supervision of facility staff, the resident developed stage 4 pressure injuries. On 09/26/2024, from 04:05pm-6:00pm, the department interviewed staff (S1) and resident (R2) regarding the allegation. R1 could not be interviewed because R1 has passed away on 8/01/2022 of natural cause: Cardiopulmonary arrest due to Atherosclerosis. 1 of 1 staff denied the allegation. Staff (S1) stated that R1 resided at the facility from June 27, 2019, to August 01, 2022. S1 stated that when R1 first arrived at the facility on June 27, 2019, the pressure injuries were small scabs. S1 stated that R1 was treated by several health agencies during R1s stay at the facility. While at the facility, S1 took R1 to the hospital as R1 sustained a stage four pressure injury to R1s coccyx and ankle while R1 was at the facility. S1 stated R1 was being repositioned every 2 hours as instructed by the home health agency. The department reviewed the medical records from Comcare Home Health and All Care Home Health Medical Records for R1 and observed that on 12/02/2021 R1 was diagnosed with three pressure injuries: Wound 1, Location: Rt ankle, Type: Pressure Ulcer/Injury, Stage: DTPI (Deep Tissue Pressure Injury). Wound 2, Location: Lt heel, Type: Pressure Ulcer/Injury, Stage: DTPI. Wound 3, Location: Lt buttock, Type: Pressure Ulcer/Injury, Stage: Stage 3. Additionally, on 02/17/2022 R1 was diagnosed with two pressure injuries: Wound 1, Location: coccyx, Type: Pressure Ulcer/Injury, Stage: Stage 3. Wound 2, Location: Rt ankle, Type: Pressure Ulcer/Injury, Stage: Stage 3. R1 was consistently under the care of All Care and Comcare Home Health to treat the wounds. Based on the records reviewed, there is no sufficient evidence to prove the facility’s failure of providing appropriate care to the resident by seeking timely medical intervention for stage 2 pressure injury development that led to its progression to stage 4 pressure injuries. With the resident’s health conditions, the development and progression of pressure injuries could not have been avoided even when appropriate treatments were being rendered. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff neglect resulted in resident developing stage 4 pressure injuries. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #2- Facility staff neglect resulted in resident requiring emergency surgery. The details of the complaint alleged that the resident (R1) required emergency surgery after being at the facility for the first six weeks due to dehydration and severely impacted bowels. On 9/13/24, 9/26/24, 11/26/24, and 12/10/24 the department interviewed staff (S1-S2), and witnesses (W1-W4) regarding the allegation. R1 could not be interviewed because R1 has passed away. 2 of 2 staff denied the allegation. S1 stated that they informed witness (W2) that R1 was bleeding from R1s private area; and S1 also alerted R1s primary care physician. S1 stated that the PCP told them to monitor the resident for now. S1 stated that later that night R1s bleeding stopped and S1 alerted (W2) about it. Subsequently, the next day, S1 took R1 to the hospital for an examination. R1 was then diagnosed with three polyps and had to have emergency surgery to remove them. Witness (W1) contends it was staff neglect, witness (W4) stated that polyps take on average several years to develop (primary care physician), while witness (W3) had no knowledge of the incident. The department reviewed Kaiser Permanente’s medical records for R1 and based on records reviewed there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of supervision leading to R1 having to have emergency surgery. Per R1s medical records, there was a telephone call placed to Kaiser on August 09, 2019, regarding a concern that R1 sustained vaginal bleeding earlier in the same morning. R1 was then taken to the Emergency Department (ED) at Kaiser on August 10, 2019. R1 was diagnosed with polyps while R1 was in care at the facility and underwent surgery. Based on the evidence and interviews conducted; the facility acted timely to address R1s bleeding as they contacted the hospital and brought R1 into the ED for treatment. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff neglect resulted in resident requiring emergency surgery. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Facility staff admitted resident into the facility without the consent of the authorized representative. The details of the complaint alleged that the facility admitted the resident into the facility without the consent of R1s appointed power of attorney. On 09/06/24, the department interviewed staff (S1) regarding the allegation. 1 of 1 staff denied the allegation that the Facility staff admitted resident into the facility without the consent of the authorized representative. Staff stated that the resident was admitted to the facility on 06/27/2019 by a family member. Subsequently, the family member produced a document showing they had power of attorney and could act on behalf of the resident. S1 stated the resident was admitted to the facility on good faith and remained in the facility based on the documents received. Report Continued On LIC9099-C The department reviewed the Power of Attorney (Dated: 07/19/2019), Resident Appraisal (Dated: 06/27/2019), and Physicians Report (Dated: 06/27/2019) and observed that the facility had the required documents to admit the resident to the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff admitted resident into the facility without the consent of the authorized representative. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #4- Facility staff did not assist resident with medical appointments as needed. The details of the complaint alleged that the facility failed to follow through on medical appointments for the resident. It was reported that Kaiser physicians ordered home health care services for the resident, however facility staff never followed through and made the appointments for the resident to receive home health care as needed. On 09/26/2024, from 04:05pm-6:00pm, the department interviewed staff (S1) regarding the allegation. Staff (S1) stated that R1 only missed one or two appointments during their stay at the facility and it would be due to R1 feeling too tired to attend the appointments. S1 also stated that when appointments were missed, they would reschedule it. The department reviewed medical records from Kaiser Permanente, and all appointments for the resident. The department also reviewed records for the health agencies that were working with the facility. The facility administrator (S1) stated that there were three home health agencies who worked with R1 while R1 resided at the facility: Omnicare, Comcare, and All Care Home Health, and that they were all working together to help the resident. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not assist resident with medical appointments as needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint. An exit interview was conducted with Precious Dennis, Administrator, and a hard copy of this report was provided.