complaint·November 20, 2025

Between 08/12/2025 and 09/29/2025, Investigator Sonia Torre conducted interviews with relevant parties including facility staff, residents, and family. Investigator Torre also obtained and reviewed additional documents including hospital and hospice records, law enforcement reports, and wound care records. During today’s visit, the LPA, ED, and Memory Care Unit Director conducted a brief physical plant tour at 10:35AM, and no immediate concerns were observed. The following was then determined: Allegation: “Due to staff neglect, a resident sustained an unstageable pressure injury while in care.” It was alleged that due to staff neglect, Resident #1 (R1) sustained an unstageable sacral pressure injury while residing at Belmont Village Encino. R1 had a diagnosis of dementia, hypothyroidism, and congestive heart failure with a documented history of motor impairment and skin breakdown and required assistance with activities of daily living. Facility Nurse Assessments noted R1 had dry skin in the sacral area, discoloration and bruising on the right extremity toe and anterior body, and an open sore on the front head area and redness on the sacral region. Home Health Records from 04/23/2025 to 05/21/2025 noted R1 received services for fungal skin infections and development of Stage II pressure injuries on the buttocks. Wound care was initiated for Stage II injuries on the right buttocks, right posterior upper thigh, and right medial upper thigh. On 05/17/2025, it was documented that the pressure injuries on the right lower buttocks and right upper thighs had healed and required no further care. Hospice Records from 05/22/2025 to 07/17/2025 revealed R1 received two (2) skilled nurse visits and three (3) aide visits per month. Wound care services were provided on 05/31/2025, 06/05/2025, 06/16/2025, 06/17/2025, 06/21/2025, and 06/23/2025. Report Continued on LIC 9099-C On 06/11/2025, R1 was documented to have four (4) Stage III pressure injuries: right posterior lower buttocks, left posterior lower buttocks, left posterior upper buttocks, and left posterior buttocks. On 07/16/2025, facility staff reported wound changes were observed with R1 experiencing increased pain. R1 was transferred to Encino Hospital Medical Center on 07/17/2025 for a higher level of care to address the progressing wounds. R1 was at high risk for further skin breakdown due to impaired nutritional status, limited mobility, multiple comorbidities, altered continence, and impaired skin integrity. Hospital records noted a pre-operative diagnosis of unstageable sacral pressure injury, later determined post-operatively to be Stage III. R1 was discharged to a Skilled Nursing Facility (SNF) on 07/24/2025. Interview with R1’s Responsible Person revealed that R1’s condition declined over the course of three (3) years and required full assistance except for feeding. They reported no concerns about the level of care R1 received and confirmed awareness of R1’s pressure injuries, which were treated through Hospice and wound care. R1 was observed to be repositioned throughout the day; despite this, R1’s wounds did not improve. Interview with four (4) staff confirmed R1’s declining condition and lack of wound improvement. Staff documented R1’s change of condition, notified their Supervisors and Hospice, and it was ultimately determined that R1 required a higher level of care than Hospice could provide. Staff also noted R1 had chronic skin breakdown and eczema, contributing to further complications. Based on record review and interviews, while R1 did experience pressure injuries, there is insufficient evidence to determine that staff neglect caused or contributed to the unstageable sacral wounds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C Allegation: “Staff refused to accept resident back from hospital” It was alleged that the facility refused to accept R1 back from the hospital due to their wounds. R1 was transferred to the Hospital on 07/17/2025 and subsequently discharged to a SNF on 07/24/2025. Facility Administrators reported they were not notified by the hospital of R1’s transfer to the SNF. The Director of Nursing later observed R1’s name on a room assignment at the SNF during an unrelated visit and inquired about the transfer. Interview with R1’s Responsible Person confirmed R1 would temporarily reside at the SNF for wound care before returning to Belmont Village Encino. The Director of Nursing also confirmed that R1 would be accepted once wounds improved. During today’s visit, the LPA confirmed R1 returned to the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.