Complaint·July 11, 2023

Allegation: Resident developed pressure injuries while in care. – Unsubstantiated. According to complainant, R1 was admitted to the hospital on 1/7/2023. Complainant’s concern is regarding R1’s significant decline in health which resulted in pressure injuries and hospitalization. The Department received and reviewed R1’s medical records. On 1/7/2023 at approximately 1056 hours, R1 was admitted to Kaiser Permanente Medical Center Roseville via ambulance. On 1/8/2023, medical staff performed a wound assessment and located an unstageable pressure injury on R1’s coccyx (bony prominence). The wound’s length and width was 0.5 centimeters by 0.5 centimeters with full thickness tissue loss and slough. The etiology of the wound is “community acquired pressure injury.” R1’s discharge doctor explained that the term “unstageable” is used when the exact state of a wound cannot be identified accurately. R1’s doctor stated, according to R1’s hospital notes, would determine R1’s pressure injury as “probably stage 2.” The Department interviewed and received statement from R1’s home health nurse (HHN). On 01/05/2023, R1 was last seen by HHN two days prior to hospital admission. During R1’s head to toe check on 01/05/2023, HHN stated R1 was “clean” from any pressure injuries but was at high risk for those types of injuries. HHN did not recall seeing pressure injuries on R1 days before hospital admission. The Department gathered statement from facility administrator. On 1/07/2023, administrator gave R1 a sponge bath approximately three (3) days before 1/07/2023. Administrator recalled observing R1’s buttocks being red but did not see an open wound. Allegation: Resident had a serious decline in health while at facility. – Unsubstantiated. According to complainant, R1’s significant decline in health which resulted in R1’s severe weight loss. According to Home Health records, R1 was taking five (5) or more medications, had two (2) more hospitalizations in the past six (6) months, and required “around the clock” care. Home Health noted R1 as “failure to thrive” as of December of 2022. HHN described R1 as “frail” during start of care visit on 12/30/2022. HHN requested the facility staff to weigh R1 daily to ensure R1 was not losing weight too fast and in an unhealthy manner. Interview statement received from administrator indicated, staff were unable to weigh R1 daily due to lack of mobility and refusal. Administrator indicated R1 did not have a big appetite and needed to encourage R1 to eat regularly. R1 was able to walk without assistance and would take walks around with block with administrator. Approximately three (3) days before R1’s admission to Kaiser Permanente on 1/07/2023, R1 began declining in health. R1 stopped walking approximately five (5) days before 1/07/2023. R1’s discharge doctor explained that a failure to thrive diagnosis can be the “natural progression” of a patient’s decline in health. Doctor explained there is no way to combat the “process of aging” and some symptoms can be lack of appetite and weight loss. Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited during today’s visit. Exit interview conducted with administrator, copy of report was provided. Allegation: Financial abuse. – Unfounded. According to complainant, the facility called Kaiser to inform them that R1’s medication and rent payments were unable to be processed. R1 was unable to recall pertinent bank information. Complainant called the facility to gather more information about R1’s bank information. Facility’s administrator told complainant that R1 was ‘settled up” with payments and the check bouncing issues occurred a month prior. Complainant was concern that there may be financial fraud occurring and found it “odd” that the facility would bring up payment issues when R1 was currently up to date with rent and medication payments. The Department investigated the alleged allegation. R1 went to the hospital and was moved to a higher level of care. R1’s belongings were left at the facility. R1’s responsible party (RP), contacted new facility to pack up and take all R1’s belongings which includes, purse with checkbook. The Department subpoenaed bank records and no issues concerning the licensee or staff from Loving-Kindness Carehome LLC were identified. Based on records reviewed and interviews, the above allegation is found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies have been cited during today’s visit. Exit interview conducted and report was provided to the facility.