complaint·December 15, 2025

On 05.06.2024 LPAs Ngo-Castaneda initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but are not limited to R1’s Physician’s Report, Admission Agreement, Resident Appraisal, Needs and Service Plan dated 10.28.2023 and other records related to the complaint allegation. LPA conducted interviews with the Administrator and three (3) out of six (6) residents, who were able to communicate. On 6.5.2024 SI Ferris conducted interview with, administrator; Staff #1 (S1) at 11:30AM, staff #3 (S3) at 12:00 PM, staff #2 (S2) at 1:30PM, resident #3 (R3) at 2:30PM, resident #6 (R6) at 2:45PM, resident #4 (R4) at 3:00PM, resident #1 (R1) at 3:30PM. Wound specialist was interviewed on 7.2.2024 at 8:30AM. Between 7.11.2024 and 07.23.24 hospice nurses, hospital social worker and nurses were interviewed. On 06/12/24 SI Ferris reviewed R1 medical records from hospice and hospital. (The records were subpoena on 05/16/24) Allegation#1: Due to neglect, resident received skin tears and multiple pressure injuries. The investigation revealed that R1 had been living at this facility since 10.28.2023. Upon R1’s admission to the facility, R1 was noted to have infection and inflammatory reaction and other complicated health conditions. Per assessment records from hospice, on 10/28/23 at the time of admission to the facility, R1 had stage 2/3 wounds. The Administrator and staff have knowledge of R1’s health conditions and complications. Staff revealed that they were not aware of R1 having skin tears. R1 was private person and was able to care for their ADL including bathing, and toileting. Although facility staff were advised by hospice nurses how to assist R1 when hospice was not present, staff relied on wound care specialists and hospice nurses assuming that they were providing care that R1 needed. A review of facility records revealed that R1 was receiving Hospice services which was initiated prior to R1’s admission to the facility. Between 08/21/23 and 05/01/24 R1 was receiving wound care services by wound care specialists, visiting R1 once a week. A review of the hospice visits and wound care notes, between 01/24/2024 through May 1, 2024, revealed that “R1 needed maximum assistance with all activities of daily living. (ADL) which included standing with maximum support. Required assistance communicated to the caregiver. The caregivers were also reminded “to reposition the resident every two hours to prevent pressure ulcers and to “promptly notify hospice of any concerning changes in the patient`s condition…” Continue to LIC 9099-C On 04/05/24 the wound care specialist identifies a second wound as a “new vascular stasis ulcer” which takes longer to heal. Between 04/05/24 and 04/30/24 wound care visit report identified that both wounds were not healing. On 05/01/24, R1 had nose bleeding for 3 days and leg bleeding. On 05.02.2024, R1 was admitted to the hospital with knee wound bleeding, unstageable pressure Injury and Stage 3 Pressure Injuries on right and left posterior thighs. Overall investigation revealed that R1 was admitted to the facility with complicated health conditions and stage 3 pressure injury with large amount of drainage. While R1 continued to remain in the facility, conditions(s) of the pressure injuries were worsening. Although hospice nurses and wound care specialists were responsible for providing wound care, staff failed to follow instructions received from the health care professionals to provide required assistance and reposition R1 every two (2) hours. Based on the interviews and record review, the facility admitted and retained R1 with prohibited health conditions and failed to assist R1 as per instructions received by medical professionals. Staff also failed to seek medical attention in a timely manner when R1’s condition was worsening. Therefore, the allegation is Substantiated at this time. Allegation #2: Staff are not following Hospice Care Plan It was alleged that facility staff are not following hospice care plan. Interview with staff revealed that they did not assist R1 with ADLs and did not touch or assist R1 with repositing since R1 did not want to be touched. Staff rely on medical personnel to provide required care for R1. A review of R1’s hospice records conducted by the LPA Ngo-Castaneda on 12/06/25 revealed that facility staff were instructed to rotate and reposition R1 every two (2) hours. Per hospice records “Patient (R1) needed maximum assistance with all activities of daily living (ADLs) which included standing with maximum support. Required assistance communicated to the caregiver. The caregivers were also reminded to reposition the resident every two hours to prevent pressure ulcers and to “promptly notify hospice of any concerning changes in the patient`s condition…” Continue to LIC 9099-C Based on the information obtained during the course of the investigation the allegation is deemed substantiated at this time. The following deficiencies were issued and recorded on LIC9099D. Licensee was informed that an immediate Civil Penalty of $500.00 will be issued to the facility at the time of this visit. Additional civil penalty maybe be assessed at later time based on Health and Safety Code 1569.49 Exit interview was conducted. Appeal rights discussed and a copy of report was issued.