Complaint·November 7, 2025

Allegation: Resident sustained multiple pressure injuries due to lack of care from staff Investigation Finding: Substantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2, S3, S4) & R1’s responsible party (POA): and reviewed resident (R1) documents. Review of R1’s files showed no documentation of any pre-existing pressure injuries upon admission. POA also confirmed that R1 moved into the facility on 04/27/25 without any pressure injuries. During interview, the Memory Care Director also stated that R1 was admitted with no pressure injuries. The Department observed that R1’s care plan included the skin treatment routine of keeping the skin clean and dry, apply over the counter skin care cream, and monitor for any redness, irritation, and/or open skin, however, the facility’s Task Administration Record showed no care entries for the Skin Treatment Routine were performed from April 27, 2025 through May 11, 2025. Three caregiver staff reported to the Department that they had changed R1s incontinence wear, clothing, and provided a shower, and denied noticing anything other than chafing or surface level redness. However, R1 was picked up by POA on 05/11/25 to return home after living at the facility for about 15 days and on the same day, the POA discovered a pressure injury and took R1 to the hospital where she was diagnosed with stage 3 infected pressure injuries. 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 sustained multiple pressure injuries due to lack of care from staff was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining multiple pressure injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury. Continued on next page, LIC 9099-C pg2 Allegation: Staff did not ensure resident’s needs were met while in care Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff (ED, S1 S2, S3, S4), responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted to at the facility on 04/27/25 for respite care and resided at the facility for 15 days until 05/11/25. R1 was assessed as having cognitive impairment, was ambulatory with a cane/wheelchair, neededs standby assistance transferring in & out of bed, total assistance with ADLs (showering, incontinence care, toileting, grooming, dressing, feeding) and was a high risk for falls. POA agreed to place R1 in the memory care unit so that she R1 can have additional staff care support. Review of R1’s files showed no documentation of any pre-existing pressure injuries upon admission. During staff interviews, some staff stated they had noticed redness near the coccyx during R1’s stay, but since it appeared to be only surface level, they did not report any concerns. Staff denied observing any pressure injuries, although the Task Administration Record (TAR) for R1 showed no entries for “Skin Treatment Routine” were performed from for 04/27/25 through 05/11/25. The Skin Treatment Routine was identified as a service need. 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 staff did not ensure resident’s needs were me while in care was found to be substantiated. 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.