complaint·May 9, 2025

IB’s investigation consisted of interviews and record review, and the following revealed: On June 20, 2024. R1 admitted to hospital and was observed with two stage 3 wounds on lower left leg, an unstageable wound on left upper foot, stage 3 wound on right heel and stage 3 wound on her left knee. On June 22, 2024, R1 was discharged back to the facility against physician’s advice. On July 22, 2024, medical records from hospital reveal that R1 was admitted for weakness on July 22, 2024. Moreover, there was evidence of Stage II sacral wounds during physical exam. On July 23, 2024, R1 was discharged back to the facility. On or around July 23 or 24, 2024, records from home health reveal that wound care was provided for five wounds. Three stage 3 wounds to R1's right thigh and left leg. One Stage 2 on R1's left knee, and one Unstageable on R1’s sacrum. There were nurse visits on July 23 and 24, 2024. On November 25, 2024, IB interviewed staff from home health to confirm information from records received. Information from home health via interview and records confirm that R1 had initially six wounds that were Stage 3 as of July 4, 2024. Records also confirmed wound care provided every other day, but then increased to wound care every day. Moreover, there was indication of organ dysfunction, as a possible result from weight loss and malnourishment. Based on investigation and information obtained by IB, there was enough evidence to corroborate the allegations of R1 sustaining multiple stage 3 pressure injuries and R1 experiencing weight loss and malnourishment. Therefore, the allegations are Substantiated. Citations issued on the 9099D. Administrator advised and a copy of this report issued. Per California Code of Regulations (CCR), Title 22, an immediate civil penalty of $500 issued today for a violation resulting in R1's pressure injuries. The Licensee is informed that additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49(f) per Departmental analysis.