complaint·January 31, 2025

CONTINUED FROM FORM LIC9099 An additional follow-up visit took place on January 22, 2025. Administrator Tin Le was interviewed at that time and confirmed that records were not available for review. Additional witness interviews were attempted via email and telephone. R1’s responsible party reached via telephone did not provide any additional evidence that would corroborate the allegations. Resident R1 was admitted to the facility on June 22, 2021, and was the first admitted person once the license was obtained. Approximately 11 days after R1’s admission, R1 was taken to Orange Coast Memorial Emergency Department for decreased responsiveness and leg swelling. An Unusual Incident/Injury Report as submitted by the licensee on June 25, 2021 indicating that R1 was behaving aggressively towards staff members and displayed resistance to being provided with toileting care and having their diaper changed. The form submitted additionally states that “ resident is not cooperative ” and that R1’s responsible party was notified of the issue and requested to acquire “ an air topper mattress that help to prevent [pressure injuries] ”. Caregivers are reported to be using Calmoseptine and to be encouraging R1 to get out of bed. Email correspondence with R1’s responsible party was provided and indicates a diagnosis of gout which would be consistent with the leg swelling reported. Regarding the allegations that Staff neglect resulting in resident developing pressure injuries , Resident developed a septic infection while in care and that Staff did not properly clean resident , the following has been concluded: Based on records reviewed and interviews conducted, the presence of pressure injuries upon R1’s hospitalization is confirmed, however correspondence and reports reviewed show measures taken by facility staff to prevent or mitigate the occurrence were also in place. There is insufficient evidence to demonstrate whether staff negligence was or could have been a contributing factor in the septic infection reported. Finally, repeated attempts to provide toileting care were reported but could not be confirmed due to a lack of evidence. As a result, the three allegations are found to be Unsubstantiated, meaning that 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. An exit interview was conducted and a copy of this report was provided to a facility representative.