complaint·December 29, 2025

report, Admission Agreement, Staff Training, LIC 500, LIC 9020, hospice records, needs and service plan, discussion of hospice care plan, and relevant documents to the investigation. In addition, at 10:26 AM LPA spoke with the Administrator and other staff. At (time) LPA interview with five (05) out of six (06) residents. On 11.5.2024, LPA requested R1’s medical records from the hospital. In addition, on 9.16.2025 LPA requested and received hospice records. During this investigation R1 was no longer present at the facility. Other Residents interviewed during investigation did not address any concerns regarding their care at the facility. Staff interview revealed that staff assisted R1 with all activities of daily living. They stated that they were not assisting R1 with the wound care. Staff were relying on hospice nurses to provide assistance with wound care. A review of hospice records revealed that between January 2023 and October 2024. on and off R1 developed unstageable, stage 3 and 4 pressure injuries Per hospice records on 10.07.2024 R1 had unstageable pressure injury on Sacro-Coccyx area and left (L) heel. Hospital records revealed R1 was admitted to the hospital on 10.28.2024, at which time R1 was presented with unstageable, Stage 3 and Stage 4 pressure injuries. Based on inspection, observation, interviews and record review, facility admitted and retained a resident with prohibited health condition unstageable, Stage 3 and 4 pressure injurie, and staff at the facility failed to provide appropriate care and supervision to assist R1 with pressure injuries. Therefore, the allegation of "Staff neglect resulted in a resident sustaining multiple pressure injuries. ” is deemed substantiated at this time. The following deficiencies were issued and recorded on LIC9099-D. 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.