complaint·September 25, 2025

(Continued from LIC 9099) On February 5, 2025, R1 developed a wound on their left hip and on the heels of their feet. R1 received Home Health services through Kaiser Permanente for catheter care and heel wounds. On February 5, 2025, R1 was transported to Kaiser Hospital due to a ruptured urethra and for further evaluation of the hip and heel wounds. R1 returned to the community on February 6, 2025, after hospital treatment with a diagnosis of Urinary Tract Infection and orders for medication treatment. Four days later, on February 10, 2025, the Health Care Director requested R1 be sent out to Kaiser Hospital for further medical evaluation for the hip and heel wounds that were not improving. Resident was treated and admitted to the hospital and was discharged on February 18, 2025, to a Skilled Nursing Facility. During the course of treatment the Power of Attorney (POA) received communication from both facility staff and Home Health regarding the hip and heel pressure wounds. Facility had spoken to the Power of Attorney (POA) on January 29, 2025, requesting the resident receive hospice care for the open wounds in order for the resident to return to the facility. POA declined hospice services due to a scheduled surgery for kidney stones. The physician was notified and the nurse treated the affected area. POA was aware of R1’s declining health and management discussed with POA to consider a personal caregiver to provide supervision to prevent further falls or injuries but family was not able to provide a personal caregiver. Care staff would do frequent body checks and rotate R1, based on R1’s service plan, which was documented by facility staff and Home Health. Due to statements and documents, nurses’ progress notes and home health notes there is not enough information to support the allegation that Resident #1 sustained stage 4 pressure injury while in care due to Neglect/Lack of Care and Supervision. The allegation is Unsubstantiated. It was alleged that Resident sustained a fracture while in care due to lack of care and supervision. Resident #1 (R1) had eleven unwitnessed falls in 2023-2024 in their bedroom; due to R1 getting out of bed and walking. Per Physician’s Report dated October 31, 2024, R1 is unable to transfer to and from the bed and is non-ambulatory. R1 also is diagnosed with Mild Cognitive Impairment. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) The Department reviewed Unusual Incident Reports for R1’s unwitnessed falls for the following dates: 8/10/2023, 8/22/2023, 9/24/2023, 9/25/2023, 10/27/2023, 03/22/2024, 03/25/2024, 04/01/2024, 04/10/2024, 05/04/2024, 05/09/2024 and 07/02/2024. R1’s needs and service plan was updated on 08/22/2023 following their first two falls and again on 12/23/2023 following their next three falls. After continuing to sustain falls, the facility updated the needs and service plan on 03/19/2024; 06/26/2024; 09/21/2024; and 11/20/2024 with suggested fall interventions which included: toilet resident before and after meals and before bedtime, frequent checks, involve resident in activities during the day and monitor for medication side effects. On April 4, 2024, management implemented fall risk prevention measures by requesting a low bed, frequent checks on R1 and discussed extra care and supervision. POA was unable to provide a personal caregiver but facility staff conducted additional status checks, every thirty minutes on R1 to prevent falls. Record review did not report any injuries related to the falls; both by the facility and home health. On February 10, 2025, R1 was transported to Kaiser Hospital due to pressure wounds not improving and to be evaluated by an orthopedic surgeon regarding a fracture. R1 was diagnosed with a left femur fracture. . The surgeon reported the fracture to be old, chronic and nonoperative and the fracture was healing and surgery was unnecessary. No time frame was provided and the injury was reported to be old. Facility staff accompanied R1 to appointments and there is no documentation regarding R1 having a fractured hip prior to diagnosis. R1 was treated at the hospital and was given medication for pain and discomfort. Although R1 had multiple falls and sustained a fracture, it remains unclear the source of cause for the fracture and therefore whether it was due to neglect. There is not enough information to support the allegation that the: Resident sustained fracture while in care due to lack of care and supervision. Based on interviews conducted and records reviewed, 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 that the: Resident sustained a stage 4 pressure injury while in care and the Resident sustained a fracture while in care due to lack of care and supervision are Unsubstantiated. An exit interview was conducted with Kurt Knauer, General Manager, and a copy of this report was left at the facility.