complaint·May 2, 2025

Allegation: Staff did not notify authorized representative of incident. It is alleged that on January 20, 2025, resident (R1's) authorized representative observed a bruise under the resident's right eye and questioned staff about the incident. A total of seven staff were interviewed. Based on interviews conducted, the findings indicate that on January 17, 2025 at approximately 7:30 AM, morning shift caregiver staff (S3) observed the bruise. Caregiver immediately reported the observation to AM shift med-techs, whom typically contact the resident's physician, hospice, and responsible party. However, in this case the two (2) AM med-techs on duty on January 17, 2025 failed to report the incident to family and forgot to communicate the incident with the next shift med-tech. Additionally, the bruise incident was not documented on the facility electronic software system or charting notes. Per Charting Notes records, staff did not document the bruise that was observed on January 17, 2025, but a Skin Integrity Monitoring Form was completed. Staff acknowledged the incident was not reported to R1's responsible party and documentation/communication protocols were not followed. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff are not repositioning resident every 2 hours. It was reported that hospice resident (R1) required repositioning every 2 hours due to a sacral pressure injury, but despite regular hospice wound care the pressure injury was getting worse. Seven (7) staff were interviewed. Caregiver staff stated they checked on the resident every 2 hours, and as the resident's health declined staff were checking on the resident at least every hour. Staff stated sometimes R1 refused to be repositioned every 2 hours because the resident preferred to lay in bed in a flat position due to pain when rotated to the side. Staff acknowledged that sometimes the NOC shift caregiver staff did not log in routine checks. It is unknown if they performed rotations on the resident. One of the NOC shift staff (S8) in question was terminated on January 24, 2025 for misconduct and suspicions of improper handling of cognitively impaired residents during incontinence changes. Bedridden residents were interviewed. One (1) resident stated staff are not repositioning every 2 hours, especially during night time. Charting notes [1/1/25 - 1/29/25], records indicate that the majority of the time R1 was routinely being checked every 2 hours. However, on several dates staff checked the resident past the required repositioning time. In addition, many of the documented checks did not specify whether the resident was repositioned every 2 hours. There is sufficient evidence to corroborate the allegation. Allegation: Resident received an unexplained injury. On January 17, 2025, AM shift caregiver staff observed a bruise under resident (R1's) right eye. The injury was documented on a Skin Integrity Monitoring Form and med-tech staff were notified. None of the residents interviewed reported staff rough handling incidents that have caused bruising. All seven (7) staff interviewed confirmed that resident (R1) had a bruise under the right eye. Staff interviews revealed that former NOC shift staff (S8) stated that when the resident was being turned the resident's hand hit their own face. Staff stated that R1 was experiencing agitation behaviors during repositioning assistance, and may have unintentionally hit themselves. The majority of staff interviewed do not believe the bruise was intentionally caused by malicious intent, but confirmed the resident sustained an unexplained bruise. Picture evidence was obtained. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Business Office Manager Andrea Lopez. A copy of the report and appeal rights were provided.