complaint·August 29, 2025

Investigation revealed the following: Allegation: “Resident developed stage 3 pressure injury while in care”, it is being alleged that R1 developed a stage 3 pressure injury while in care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries but had no pressure injuries at the time of assessment and the goal for R1 was not to develop any pressure injury. From 11/10/2024 to 12/24/2024, R1 received Home Health services; Home Health staff instructed facility caregivers to check skin for any signs of pressure injuries and change position of R1 every two hours. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. On 12/28/2024, Progress Notes indicates that the Primary Physician diagnosed R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm, there is no documentation indicating that R1’s Primary Physician performed wound care from 12/28/2024 to 01/28/2025. The facility did not maintain a record of R1 being repositioned every two hours or of care provided with all aspects R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that staff would not reposition them every two hours. On 04/29/2025, 2 out of 6 staff indicated that staff would not reposition residents if they were in wheelchairs, unless residents requested it; 5 out of 6 staff confirmed that on December 2024 they saw an injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx). Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed please see LIC421IM. Allegation: “Licensee is retaining a resident with a higher level of care need”, it is being alleged that R1 was retained at the facility even though R1 required a higher level of care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries and the goal for R1 was not to develop any pressure injury. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. On 12/28/2024, Primary Physician Progress Notes diagnosis R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. From 12/28/2024 to 01/28/2025, there is no documentation indicating that R1’s Primary Physician performed wound care. The facility did not maintain a record of R1 being repositioned every two hours and did not provide documentation of all aspects of care performed to address R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that they developed a pressure injury while in care at the facility. On 04/29/2025, 5 out of 6 staff confirmed that on December 2024 they saw a pressure injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx); 2 out of 6 staff confirmed that on December 2024, after R1 came back from the hospital (on 12/28/2024), R1 was no longer receiving Home Health services. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Deficiencies were cited. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the Assistant Administrator, Olivia Alvarado.