complaint·March 24, 2026

The investigation revealed the following: Allegation: Resident sustained multiple pressure injuries due to staff neglect (investigated by IB) It is alleged that the facility’s neglect caused the resident R1, tosustain a fever, diarrhea, pressure ulcers in his heels/ coccyx, and sepsis while in care at the facility. This allegation was investigated by Investigations Branch (IB) investigator D. Seng which revealed the following: Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility’s neglect led R1 to sustain to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. R1 was placed at the facility from 04/01/2025 to 05/05/2025. Per my interview with the facility staff, R1 was repositioned at least once every two hours. He/she was on home health and received two visits weekly via his Neo Gen Registered Nurse, who was directly responsible for his/her wound care. RN stated that R1 sustained stage two pressure ulcers to his/her right and left buttocks on 04/02/2025 and these wounds never progressed to a stage three or above at any time while R1 was at the facility. RN added that R1 was discharged to Kaiser on 05/05/2025 and his/her pressure ulcers only became worse during his/her stay at Kaiser. R1’s PCP stated that the facility would not have any way to know if he/she was septic unless there were laboratory tests conducted. PCP added that they was in communication with R1 and had a phone encounter with him/her on 04/23/2025. W2 and R1’s PCP added that it was difficult to prevent sepsis or the pressure ulcer on his/her coccyx due to R1’s gunshot wounds, his/her lack of mobility, and his/her catheter. The staff stated that they would contact R1’s PCP/ Wound Care Nurse/ R1’s family immediately when there was a change of condition. Based on the evidence and interviews conducted, the allegation of Neglect/ Lack of Supervision was unsubstantiated. Allegation: Staff did not seek timely medical care for resident in care (investigated by IB) It is alleged due to the facility’s neglect due, and lack of timely medical care caused the resident R1, to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility’s neglect due to lack of timely medical care led R1 to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. Per R1’s home health nurse W1, he/she stated that R1 sustained stage two pressure ulcers to his /her right and left buttocks on 04/02/2025 and these wounds never progressed to a stage three or above at any time while R1 was at the facility until he/she was discharged to Kaiser on 05/05/2025 R1’s PCP added that they believed the facility staff followed his/her care plan, did their best to meet R1’s hygiene standards, and sought timely medical care. They added that R1’s condition was unavoidable and difficult to prevent. Based on the evidence and interviews conducted, the allegation of Neglect/ Lack of Supervision was unsubstantiated . In regard to the allegation” Facility staff did not assist resident in a timely manner”, It is alleged that during a visit it was observed a resident was left screaming for help and facility staff did not respond. During interview with Licensee, Administrator, and staff five (5) out of five (5) staff stated that they always responded to residents. Staff stated that residents have a buzzer and if they need help, they can just press it and staff will come. Administrator stated that R4 does not like to use the buzzer and that he/she like the attention of staff and if R4 needs help R4 will just scream. During interviews with residents one (1) resident stated that staff would leave them for hours because they were understaffed and to busy, two (2) residents stated that staff assisted them in a timely manner, R3 stated that if staff were busy you might have to wait a little bit, but they would come, and one (1) resident was confused by LPA’s questions. During interviews with residents LPA observed R4 yelling for help and when LPA and staff entered room R4 wanted staff to sit with him/her and hold there hand. Staff held R4’s hand and resident calmed down. In regard to the allegation” Staff did not ensure that resident's hygiene needs are met “, It is alleged that facility failed to provide R1 with frequent baths resulting in body odor. During interview with License, Administrator, and staff four (4) out of five (5) stated that residents are given baths 2x a week or more if needed. One (1) staff does not assist in bathing so was unaware of how many times residents are bathed. S2 stated that R1 would only let them bathe him/her and that he/she requested a sponge bath more than 2x a week and S1 would do it. During interviews with residents, two (2) out of four (4) stated that they were bathed regularly and had no problems with hygiene R4 was confused and could not answer the question. One (1) resident stated that staff did not bathe him/her. R1 stated that in the 35 days of stay they were only bathed maybe three (3) time by staff and maybe once by a home health nurse. In regard to the allegation” Staff did not follow instructions from care plan”, It is alleged that during the time of R1’s stay at the facility staff was trained by a home health agency to provide physical therapy three times per week, as part of recovery plan. Despite this clear instruction, not a single physical therapy session was conducted During interview with Administrator, and staff all five (5) stated that home health agency was in charge of PT and OT. Staff stated that only home health took care of therapy staff was not trained for that. During interview with R1 it was revealed that home health care came 2x a week for physical therapy. R1 stated he/she thought staff was supposed to help him/her with physical therapy. LPA obtained documents from Home Health Care dated 04/02/2025 that an order was placed for therapy 3x a week for 3 weeks effective 04/02/2025. Documents reviewed did not indicate staff was to assist with any physical therapy. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to licensee.