Complaint·November 6, 2025

Per three of three staff, it is facility protocol to empty all toileting equipment, whether it is full or not, two to three times per shift. Regarding the allegation, Staff did not safeguard resident's personal belongings, the following was revealed: It is alleged staff did not safeguard R1’s wheelchair leg supports. Interviews were conducted with eleven facility residents and three facility staff. During their interview, R1 stated that on August 17, 2025, they were wheeled to breakfast by Staff 2 (S2). Per R1, they requested that S2 take their wheelchair leg supports off. S2 complied and the leg supports were placed in R1’s room. Per R1, upon returning to their room, the leg supports were still there, however went missing later the same day. Per R1, after reporting their leg supports were missing, the facility replaced them with "almost identical" ones. Two of ten additional facility residents interviewed were unable to confirm or deny the allegation and eight of ten facility residents denied having anything missing or having any stolen items, including wheelchair leg supports, or any other ambulating assistive device. During their interview, S2 denied the allegation and stated they were not aware R1 had been missing their wheelchair leg supports. During their interview, S3 stated R1’s wheelchair leg supports were immediately replaced upon R1 reporting them missing, however, were later found to have been in R1’s bedroom all along. Regarding the allegation, Staff did not ensure resident’s assistive equipment needs were met, the following was revealed: It is alleged R1’s did not receive a hospital bed with half bed railing, and air mattress. During their interview, R1 stated Kaiser provided them with a hospital bed with bed railings and an air mattress, however these items were never provided to R1 at the facility. During the course of the investigation, Kaiser was contacted, and a Kaiser Representative (KR) confirmed a hospital bed with half side rails and mattress had been ordered for R1 on August 20, 2025. Per KR, these items would have been delivered by third-party vender, Apria. During their interview, Apria Representative (AR) confirmed a hospital bed with half side rails and mattress had been ordered for R1, however stated the order had been received on September 20, 2024, and stated a delivery order for R1 had not been placed by Kaiser in the year 2025. AR confirmed delivery address as that of the facility, however, R1 was not admitted to the facility until August 13, 2025. During their interview, three of three facility staff denied any knowledge of Kaiser providing R1 with a hospital bed with railings and/or an air mattress. Interviews were conducted with eleven facility residents and three facility staff regarding the allegation, Staff did not properly transfer resident. (Cont. LIC9099-C) During their interview, R1 stated that during transfers they were able help themselves sit up in bed and facility staff would then pull them up by their undergarment and shorts. Per R1, upon staff doing this the thread on their clothing would start to audibly tear and the undergarment cut into the skin on their inner thighs. R1 stated that this did not cause an injury to them but could easily have. Two of ten additional facility residents interviewed were unable to confirm or deny the allegation, five of ten residents denied the allegation and stated staff assist them with transfers in a gentle manner, and two of ten residents stated they are not assisted with transfers and denied witnessing staff assisting other residents with transfers. During their interview, three of three staff stated pulling a resident by their undergarment or shorts is not part of a typical transfer, however, does occur in emergency instances, such as preventing a resident from falling during a transfer. Regarding the allegation, Staff did not assist resident with wound care in a timely manner, the following was revealed: It is alleged R1 was not assisted with wound care in a timely manner leading to wound developing maggots.During their interview, R1 stated they have wounds on their legs due to their medical condition and their wounds are treated and bandaged by Home Health. R1 was unable to provide specifics regarding the dates and times they were seen by Home Health. Per R1, about a week went by and they had not seen anyone from Home Health nor had the facility staff treated or re-bandaged their legs, when they observed a fly on their bandage. Per R1, S3 saw the fly and instructed S1 to open the bandages and maggots came out. R1 stated S3 dressed and cleaned their wounds and made sure there were no more. Per R1, on August 28, 2025, they decided to go to the hospital and was provided with wound care and given anti-biotics. During the course of the investigation, Excell Home Health was contacted, and Excell Representative (ER) stated R1 had been seen by a Home Health Nurses on August 21, 2025 and on August 26, 2025 for wound care. Per ER, R1 had also been seen on August 28, 2025, however, their notes did not specify if wound care had been provided at that time. LPA attempted to contact Home Health Nurse, Witness 1 (W1), who provided wound care for R1 on August 21, 2025 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. LPA attempted to contact Home Health Nurse, Witness 2 (W2), who provided wound care for R1 on August 26, 2025 on three separate occasions, however, W2 could not be reached to confirm or deny allegation. During their interview, S1 stated that on August 28, 2025, they had observed a fly on R1’s leg wound bandage and upon removing it, maggots were observed. Per S1, R1 spent most of their time outside and they believe a fly flew into R1’s bandage sometime on August 27, 2025, which led to the rapid development of maggots. (Cont. LIC9099-C) During their interview, S3 stated R1 was seen by a Home Health Nurse on August 26, 2025 and was provided with wound care. Per S3, on the morning of August 28, 2025, R1 reported discomfort to the wound on their leg and upon S1 removing the bandage, maggots were observed. R1 was immediately transferred to the hospital. S3 stated a Home Health Nurse had been present at the time, however had not provided wound care due to R1 being transported to the hospital. Per facility progress notes, on the morning of August 28, 2025, R1 was provided with wound care and transferred to a local area hospital for further evaluation. Based on record review of R1’s facility progress notes and due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff did not ensure resident's toileting equipment was emptied in a timely manner, if Staff did not safeguard resident's personal belongings, if Staff did not ensure resident’s assistive equipment needs were met, if Staff did not properly transfer resident or if Staff did not assist resident with wound care in a timely manner. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was left at the facility.