complaint·March 26, 2026

On 1/9/2026, LPA requested R1’s Home Health medical records. Regarding allegation: Resident sustained severe pressure injury due to staff neglect. It is alleged that on 12/28/25 R1 was admitted to the hospital with a stage 3 sacral wound. R1 was admitted to the facility on 10/25/25, record review, physician report, revealed that R1 did not have any skin breakdown. R1 was no longer present at the facility during LPA visit and was still at the hospital. All of the residents interviewed during the investigation did not address any concerns regarding their care at the facility. Home health records review revealed R1 had developed pressure injuries on their sacral, groin, heel- right and left, and buttocks. Wound started developing on December 1, 2025. An interview with staff revealed repositioning assistance was provided to avoid or relief pressure injuries, S2 and S3 provided repositioning. 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. Record reviews revealed that the staff S2 and S3 are trained and were following home health instructions on how to care for R1’s wounds . A review of home health records revealed R1 was admitted to home health on November 18, 2025. On December 1, 2025 a sacral wound stage 1 was noted by home health. On December 8, 2025 home health noted sacral wound as a stage 2, additional wound was noted to the groin area as a stage 1. On 12/12/25 , Supportive Health Group (wound specialist) noted R1 had a stage 3 pressure injuries to the left (L) buttock, which measured 6.0 cm x 5.5 cm x 0.1 cm and stage 1 pressure injuries to the right and left heel. Although R1 was receiving home health care services for wound care with wound care specialist from home health and staff were providing required assistance, pressure injuries were not healing and develop into stage 3 wound on 12/12/25. On 12/28/25, R1 was then brought to the hospital for a stage 3 wound. Facility staff retained R1 from 12/12/25 to 12/28/25 with a stage 3 wound. Therefore, the allegation is substantiated . Based on observation, interviews, and record review, there is sufficient evidence. Therefore the allegation is deemed substantiated California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D . An immediate Civil Penalty of $500.00 will be issued during this visit due to neglect/lack of care by providing care to R1 with a prohibited health condition. An additional civil penalty may be assessed at a later time based on Health and Safety Code 1569.49. An exit interview was conducted. Appeal rights a copy of the report, LIC 9099D, were provided.