complaint·October 1, 2025

Continued LIC9099-C page 2 **This report has been amended to clarify findings. It does not supersede the report delivered on 10/01/2025. ** Functional Capability Assessment (Dated 04/23/2024), Preplacement Appraisal Information (Dated 04/23/2024), Consent Forms (04/23/2024), 30-Day Notice from Resident (Dated 07/19/2024), and RN Sign-In Sheet (Dated 05/24/2024-07/10/2024). The Department also requested and received the following: Optum Health Service Medical Record for R1, Physicians Choice Home Health Medical records for R1, and Torrance Memorial Medical Center records for R1. On 10/24/2024 and 05/01/2025, the department toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit. Interviews were conducted with Staff Members #1-5 (S1-S5) as well as residents #2-4 (R2-R4) and witness 1 (W1). Resident #1 (R1) is no longer residing at the facility. The Department was able to interview the resident by telephone. The investigation revealed the following: Allegation: Resident sustained a pressure injury due to staff neglect. It is being alleged that resident 1 (R1) sustained a pressure injury on the right heel while at the facility. On 05/01/2025, Resident #1’s (R1) records were requested and reviewed. R1 was admitted to the facility per the admissions agreement dated 05/01/2024. The Physician’s Report, signed on 05/01/2024, indicated no pressure injuries upon entry to the facility. Home Health records dated 04/23/2024 show that R1 was under the care of Optum Home Health. On 06/04/2024, notes from Physician’s Choice Home Health indicated that R1 had no pressure injuries at the time of that visit. On 06/26/2024, Optum Home Health documented notes show R1 had an unstageable pressure injury on R1’s right heel. R1 received wound treatments on 07/01/2024, 07/02/2024, and 07/03/2024, as documented in Physician’s Choice Home Health medical records. On 07/03/2024, R1 was admitted to Torrance Memorial Medical Center with the following diagnoses: Stage 2 pressure injury on the sacrum, suspected deep tissue injury on the left heel, and an unstageable right foot ulcer with suspected necrosis. See continued LIC9099-C page 3 Continued LIC9099-C page 3 The Department interviewed five staff members #1-5 (S1–S5) and one witness (W1) regarding concerns about Resident #1’s (R1) foot wound. • S1 stated that R1 had a wound care nurse, but did not know the details of the wound care. • S2 reported that R1 had their own nurse who treated a foot wound. S2 was unaware of the wound’s staging and alleged that R1 had the wound upon arrival at the facility. • S3 stated that he observed a pressure injury on R1’s foot and informed R1. S3 also alleged that the wound was present when R1 arrived at the facility. • S4 confirmed that R1 had a wound on the right foot upon arrival and was seen by a nurse, but did not know which home health agency provided care. • S5 stated that R1 had their own nurse and was unaware of the wound’s staging. • W1 reported that the Clinical Coordinator from Physician's Choice Home Health noted R1 developed a pressure injury on the right heel during their time at the facility, as documented on 06/26/2024. All staff interviewed acknowledged that the resident had a pressure injury; however, none were aware of the wound’s staging or which home health agency was providing care. When a resident presents with a pressure injury, staff should receive training on appropriate wound site management and any necessary repositioning protocols. Based on the information gathered, it appears that such training may not have occurred in this instance. See continued LIC9099-C page 4 Continued LIC9099-C page 4 On 05/01/2025, between 2:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with three residents #2-4 (R2–R4) regarding the allegation, and 3 out of 3 residents stated they did not observe any resident who appeared to require wound care. 3 out of 3 residents stated that the facility is fully staffed, they were happy living here, and confirmed they are receiving the necessary care and supervision. All three residents (3 out of 3) denied the allegation and stated that their daily care needs were being met. Regarding the allegation “ Resident sustained a pressure injury due to staff neglect ,” based on record reviews and interviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D, and an immediate $500 Civil Penalty is assessed. At this time, an enhanced 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, appeal rights were discussed, and a copy of this report was provided to facility staff.