complaint·April 10, 2025

Allegation: Resident developed pressure injuries while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 06/06/22 with no pressure injuries. On 07/22/22, R1 was admitted to the hospital for generalized weakness. Review of hospital records show R1 had an unstageable pressure injury on her right buttock, a stage 2 pressure injury on her left heel, an inactive pressure injury on her right heel and an unstageable pressure injury on her coccyx. Hospital nurses provided wound care to R1’s pressure injuries. Interviews of facility staff and responsible parties and reviews of facility documents show R1 was neglected while residing at the facility. Staff (ADM, S1) gave inconsistent statements about R1’s pressure injuries. Staff denied having knowledge about the stages of R1’s pressure injuries but acknowledged that R1 did have a skin condition in the areas where the pressure injuries were located. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident developed pressure injuries while in care was found to be substantiated. Allegation: Resident developed an infection requiring resident to be hospitalized Investigation Finding: Substantiated During investigation, the department reviewed resident’s (R1) medical records which showed R1 was hospitalized on 07/22/22 and diagnosed with various stages (stage 2, unstageable and inactive) of pressure injuries on R1. Interviews with facility staff and responsible parties, and review of facility documents showed facility failed to know about R1’s sustaining pressure injuries while in care. Facility staff failed to conduct body checks, document any changes in condition and provide proper care to R1. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident developed an infection requiring resident to be hospitalized was found to be substantiated. Continued on next page, LIC 9099-C pg2 Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining pressure injuries while in care. Additional civil penalty determination is pending relating to serious bodily injuries. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Resident’ s medication is missing Investigation Finding: Unsubstantiated During investigation, staff (S2) stated resident’s (R1) authorized representative was claiming she left a prescribed medication for R1 at the facility in July 2022. Staff denied receiving any prescribed medication from POA. S2 stated POA has the habit of taking R1’s medications, creams without letting staff know that she has taken them. S2 stated that POA was looking for R1’s cream on 07/23 -07/24, Triamcinolone Acetonide. Staff looked all over for it and could not find it. POA brought the cream back on 07/25/22. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident’s medication is missing and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident’s medication is missing is unsubstantiated. Allegation: Facility did not ensure resident had an adequate amount of diapers Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement show basic services do not include incontinent supplies. ADM stated R1 had an adequate amount of diapers and that they billed POA for R1’s incontinent supplies. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility did not ensure resident had an adequate amount of diapers and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility did not ensure resident had an adequate amount of diapers is unsubstantiated. Exit interview conducted and a copy of this report provided.