complaint·July 2, 2025

Allegation: Resident developed a pressure injury while in care It is being alleged that facility staff were not assisting resident in care with repositioning which resulted in resident developing a pressure injury. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported obtaining wounds in the past but could not provide a time frame. On 01/22/25 LPA unable to interview R1 as R1 was receiving care at Cedar Sinai hospital. On 1/30/25 LPA unable to interview R1 as R1 was receiving treatment outside of Savant Of Santa Monica. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above and reported that residents that require repositioning are checked out and repositioned every 2 hours. On 7/2/25 LPA conducted a review of R1s physician report and appraisal, LPA observed there is no order that R1 needed to be re positioned. There is no documentation that R1 had a pressure injury upon admission to Savant Of Santa Monica. On 7/2/25 LPA reviewed medical records obtained from Cedar Sinai hospital, per medical records Injury was observed at the hospital but never staged. Allegation: Staff do not ensure residents bathing needs are being met. It is being alleged that facility staff are not providing showers to residents in care. On 01/22/25 between 11am- 1:05 pm LPA conducted interviews with R2-R10 regarding the allegation above, 5 of 9 residents interviewed denied the allegation above and reported receiving showers 2 times a week. 3 of 9 residents interviewed reported they do not require assistance from staff for showers. 1 of 9 residents interviewed confirmed the allegation above and reported going more than 2 days without shower assistance from staff. On 01/22/25 LPA unable to interview R1 as R1 was receiving care at Cedar Sinai hospital. On 1/30/25 LPA unable to interview R1 as R1 was receiving treatment outside of Savant Of Santa Monica. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above. On 1/30/25 LPA conducted interviews with ED, and S1-S5 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above and reported that that showers are provided 2 times a week. 3 of 6 staff interviewed reported that a resident may go more than 2 days without a shower if the resident refuses. On 7/2/25 LPA conducted a review of shower logs and observed documentation indicating showers are done twice a week, LPA also observed documented refusals from residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.