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13 | Licensing Program Analysts (LPAs) Holly Williams and Kevin Gould made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Williams and Gould met with facility administrator Aaron Fintel and together discussed the investigation details.
According to Kaiser Permanente Sacramento Medical Center medical records, R1 presented in the emergency department (ED) with four wounds located on R1’s right back, coccyx area, left foot, and left posterior heal. According to Kaiser Permanente Sacramento Medical Center medical records, the stages of the wounds were not listed, and it was only noted as, “deep tissue.” In an interview, administrator Aaron Fintel said that Fintel first noticed “discoloration” on R1’s lower back when R1 was sent to the hospital on 6/28/24. However, staff members denied seeing any pressure injuries on R1’s body prior to R1 being sent to the hospital on 6/28/24. R1 returned to Timeless Treasures on 7/1/24 with RC Hospice Care, Inc. According to RC Hospice Care, Inc hospice notes Registered Nurse (RN) reported that R1’s pressure injury to R1’s coccyx was “progressively” getting worse. However, the RC Hospice Care, Inc. hospice records did not indicate how or why the coccyx wound was getting worse. In addition, RC Hospice Care notes state the staging of the coccyx wound was inconsistent throughout the time R1 was receiving hospice care. According to RC Hospice Care, Inc. on 7/1/24 The RN staged one of the wound unstageable and the other pressure injury at a stage 2, by the end of that day, she restages the unstageable pressure injury a stage 2. In the RC Hospice Care, Inc. notes, on 7/5/24 the RN said both pressure injuries were unstageable. According to the hospice notes on 7/8/24, the pressure injuries were staged at a 2. On 7/10/24 according to the notes of RC Hospice Care, Inc. the pressure injury on the right upper back was unstageable again and the one on the coccyx was a stage 2. In an interview, the SW stated the wounds were a stage 2 and 3. RC Hospice Care, Inc. Social Worker (SW) reported that based on the RN’s notes and the home health aide’s notes, it didn’t seem like Timeless Treasures was rotating R1 enough because of the location of R1’s pressure injury. However, in an interview with S1, S2, S3, and Fintel they reported that R1 was being turned every two hours. In an interview, R1-R5 stated they did not have any concerns about the care they were receiving. According to Sacramento County Sheriff’s Office, they completed a report under number 24-243236. The deputy responded to Timeless Treasures for a possible elder abuse case. The deputy noted that R1 appeared to be “very frail and their injuries did not appear to be of an abusive or neglectful nature.” The deputy noted that staff members appeared to be doing a satisfactory job in providing for the residents’ daily needs.
The department has determined the following as it relates to the allegation is that due to staff neglect, resident's wound worsened.
Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means 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 were cited regarding the above allegation. An exit interview was held, and a copy of this report was left with Fintel.
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