complaint·December 9, 2024

Continued LIC9099-C Allegation: The resident sustained unexplained injuries while in care. Regarding the allegation resident sustained unexplained injuries while in care. It is alleged that the resident was admitted to Kaiser Permanente Medical Center for pneumonia and was observed to have various discolorations of unknown etiology (Mark) on the body. The department interviewed the Administrator #1 (A1) who stated that on 10/30/24, the Power of Attorney (POA), moved the resident #1 (R1) out of the facility and did not let A1 know where R1 would move. On 12/09/24, the department called and spoke to the (POA) over the phone who stated that POA remove R1 out of the facility due to medical necessity and personal reasons. The POA also stated that on 10/30/24, R1 did not have any discoloration or bruises on the body. The staff was very kind and took good care of R1 while residing at Everlasting Home Care. The hospitalization happened on 11/28/24, while R1 was at the new facility, The Villa. When the nurse observed R1, had pneumonia and called the paramedic who transported R1 to Kaiser Permanente Medical center and on the same day R1 was admitted. The department interviewed two residents (R2-R3) 2 out of 2 stated that they enjoyed living at the facility. The department interviewed two staff (S1-S2) 2 out of 2 stated that they do not restrain residents. The department interviewed the Independent Care Management Witness #1 (W1) who stated that W1 visits R1 twice a month at the facility and did not observe any discoloration or bruises on R1. Continued LIC9099-C Continued LIC9099-C According to W1, W1 stated that R1 is a very outspoken and would have let W1 know if any abuse happened. W1 also stated that R1 was on blood thinner that may have caused some discolorations to the body. The department records reviewed, dated 10/2024, revealed the resident left the facility a month before being admitted to Kaiser Permanente Medical Center. The department could not interview resident #4, #5, #6 due their cognitive ability. The department could not interview R1 because R1 was not available. Based on interviews, and record reviews, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Interview conducted. A copy of this report was provided to the Administrator.