complaint·November 19, 2025

It was alleged that on 5/11/2025 resident #1 (R1) was admitted to the hospital. Upon admission it was found that R1 had 4 pressure injuries on his upper and lower back. It was reported that R1 sits in a recliner most of the day or is in bed, No turning assistance was provided to avoid or relief pressure injuries. During LPA visit on 5.21.2025, it was observed that the staff continued to care for R1 at the facility. The interview with the administrator and staff at 10:44 AM revealed that staff were instructed to reposition R1 every two (02) hours. Interview with Staff #1 (S3) at 11:00 AM on 5.16.2025 confirmed that all staff had been trained by a vendor for R1’s care. LPA observed staff repositioned R1 every two (02) hours, assisted with incontinence care, and ensured their wounds were dry and free of redness. LPA interviewed R1 at 12:00 PM and stated that staff constantly check, reposition, and transfer them to their chair recliner/ bed from time to time. Interviews with five (5) out of six (6) other residents interviewed revealed they have no issues with pressure injuries. An interview with R1 family revealed that they are happy with the care given by the facility and were not aware that R1 should be at a higher level of care. A review of R1’s initial assessment revealed they had no history or signs of skin breakdown as of 11.20.2024 during admission. LPA reviewed R1 medical documents revealed that R1 was admitted to the ER on 4.22.2025 and on 5.12.2025 for other health concerns. On 4.22.2025, a stage 3 pressure injury was already observed on the thoracic (back) region. Then on 5.12.2025 at the time of admission to the hospital, the following pressure injuries were observed; sacral stage 3, extending to the right (R) buttock; Right (R) Thoracic- Unstageable; Medial Location Thoracic- Unstageable; Left hip Deep Tissue Injury (DTI) Stage 3. R1 was discharged and returned to the facility with home health (HH) wound care on 5.16.2025. Overall investigation revealed that R1 developed prohibited health condition (Stage 3 Pressure injuries) while in care of the facility. Although R1 was receiving home health care services for a wound care and staff was providing required assistance, between 04.22.25 and 05.22.25, pressure injuries were not healing. After both hospitalization R1 was readmitted to the facility with stage 3 pressure injuries, which was requiring higher level of care. Therefore, based on inspection, observation, interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page .An immediate civil penalty of $500.00 was issued for continuing to retain and readmit R1 to the facility with prohibited health condition which requires higher level of care. The Administrator was informed that additional civil penalties will be issued under Health & Safety Code 1569.49(f). Exit interview conducted. Appeal rights discussed. Copy of report provided.