Complaint·December 2, 2021

INVESTIGATION REVEALED THE FOLLOWING: Resident (R1), the alleged victim, was admitted at Wellspring Manor Senior Care Inc on 3/1/2021. The physician’s report obtained from the facility was dated 12/8/2020. LPA obtained copies of R1’s Doctor's Clinic and hospital After Visit Summaries (AVS). The facility provided the department with two appraisals dated 3/1/2021 and 6/1/2021 which do not reflect the significant changes of R1’s medical condition during her stay in this facility. R1 was discharged from the facility on 11/10/2021. Alleg ation: Resident sustained blood clots while in care. It is alleged Resident sustained blood clots while in care. The complainant reported the alleged victim, Resident (R1), was observed with a lot of pain from blood clots. Based on record review of R1’s AVS dated 9/9/2021, R1 sustained a chronic deep venous thrombosis (DVT) of both legs, leg pain, right leg pain, and deconditioning. According to the review of AVS, on 11/1/2021, R1 was prescribed Enoxaparin to prevent blood clots in the leg; On 11/13/2021, R1 was admitted to Kaiser Permanente and she was diagnosed with Pulmonary Embolism upon her discharge on 11/16/2021. Interview with Staff (S1-S5) and Residents (R1-R2), they did not see symptoms that R1 has a blood clot. Staff (S1-S5) just learned that she has a blood clot when she was discharged from the hospital. Based on the information gathered, there is no evidence that staff were negligent and therefore there is no sufficient evidence to corroborate the allegation mentioned above. Allegation: Resident sustained UTI while in care. It is alleged Resident sustained Urinary Tract Infection (UTI) while in care. The complainantt reported the alleged victim, Resident (R1), was transferred to the hospital three (3) times due to UTI. Interview with Staff (S1-S4) revealed R1 sustained UTI, however, S1 stated the caregivers clean and wash R1 at least three times a day to avoid infection. Residents (R1-R2) and staff (S5) stated they have no knowledge of any residents sustaining UTI while in care. Based on review of R1’s admission agreement, she was admitted to this facility on 3/1/2021. Based on R1’s me dical records, she was admitted to the hospital on 6/14/2021, 10/30/2021, and 11/13/2021 due to UTI. However, b ased on record review of R1’s After Visit Summary at South Bay Medical Center dated 2/23/2021 – 2/24/2021 shows R1 was provided with Patient education on Urinary Tract Report Continued in LIC 9099C Infection, no other records were attached to the summary. Record review revealed R1 has a history of UTI prior to admission at this facility. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation: Staff yells at a resident. It is alleged facility staff yells at a resident. The complainant reported there is a nurse who yells at one of the residents, they argued about everything. Based on the Department’s interview with Staff (S1-S3), a former staff (S6) had an encounter with Resident #2 who continues to yell at all staff; he calls them names, he demands them what to do in the home; he curses at them too. Staff (S1-S3) stated S6 resigned from his job because he could no longer handle the attitude of R2. S1 admitted S6 responded anxiously when R2 cursed at S6. Interview with Staff (S4-S5) and residents (R1-R2) revealed no staff yells at residents. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation: Facility is not free of trash. It is alleged facility is not free of trash. The complainant reported she observed a lot of cigarette buds around the facility. Interview with Residents (R1-R2) and Staff (S1-S5) revealed the facility is free of trash and it is clean every day. Based on LPA’s observation, the facility is clean, and no cigarette buds were observed around the outside and inside grounds of the facility. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above. Allegation: Staff not smoking in designated areas. It is alleged Staff are not smoking in designated areas. The complainant reported she observed construction workers smoking too close to the facility. Record review shows the designated smoking area is the driveway area of the home or 25 feet away from the main door of the home. Interview with Residents (R1-R2) and Staff (S1-S5) revealed no staff smoke cigarettes close to the facility. S2 and S4 admitted they smoke in the designated areas. Based on LPA’s observation during her complaint visit on 11/12/2021, she observed S1 smoking in the designated area of the premises. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. REPORT CONTINUED IN LIC 9099-C Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, " Resident sustained blood clots while in care " , "Resident sustained UTIs while in care", "Staff yells at resident", "Facility is not free of trash", "Staff not smoking in designated areas" did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited, Exit Interview conducted, and report given to Administrator Teresita Bautista.