complaint·December 30, 2025

The investigation revealed the following: Allegation: Staff did not prevent a resident from developing multiple pressure injuries while in care. It was alleged that a resident developed a pressure injury on the buttock area that was approximately the size of a grapefruit. It was further alleged that the pressure injury was severe, with visible muscle and tissue exposed and no skin covering the affected area. Additionally, it was alleged that the resident had two additional pressure injuries located on the hips. The reporting party was unsure of the staging of these pressure injuries. On 11/04/2025, between the hours of 11:25am -  11:45am, the LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation and stated the wound is unstageable and located on the coccyx of the resident. The facility defers wound care to the hospice care nurse, and the facility only changes dressings if soiled. A1 also mentioned the resident is repositioned as needed and has been provided an alternating pressure mattress (APP) that inflates and deflates to relieve pressure. The wound care nurse sees R1 three times a week, with the wound being cleaned, bandages changed, and debridement performed. On 11/04/2025, between the hours of 8:42 am -12:20pm, the LPA interviewed 7 staff regarding the allegation. 4 of 7 staff members denied the allegation and stated there were no concerns with staff properly repositioning or cleaning pressure injuries as directed by the facility and the wound care nurse. 3 of 7 staff members did not confirm nor deny the allegation and stated not working on the floor that the resident resides and did not express any concerns repositioning or cleaning the resident's pressure injury. On 11/04/2025, between the hours of 9:09am - 10:47am, the LPA interviewed 6 residents regarding the allegation. 6 of 6 residents denied the allegation and stated they have never experienced having any pressure injuries nor receiving wound care from a nurse. On 11/04/2025, LPA observed in R1's room that the facility provided the resident with a mattress that is specific for non-ambulatory or bedridden residents to help minimize pressure injuries. Report continues on LIC 9099-C On 12/22/2025 between the hours of 3:00pm - 4:30pm, LPA reviewed R1's LIC 602 Physician's Report for Residential Care Facilities for the Elderly (RCFE) (dated on 05/28/2025) which states on page 3 of 6 that Resident 1 (R1) has a history of skin breakdown located on sacral and buttocks areas. LPA conducted a records review of R1's Service Plan (dated 07/25/2025) on page 4 of 8 which states under Special Care Need resident has active wounds/skin breakdown with a history of open skin to heels and or coccyx area. Also under the transfer section of the service plan on page 3 of 8 the resident receives two person assistance with transferring and repositioning on a daily bases. LPA reviewed Hospice Care Plan from Compassionate Hospice Care, Inc (dated 11/13/2024) stated R1's treatment consist of bilateral buttocks skin care maintenance: Wash with mild soap and rinse: thoroughly with warm water, pat dry, apply calmoseptine ointment topically to buttocks skin and leave open to air daily and as needed. LPA reviewed Wound Care Progress Notes from Compassionate Hospice Care, Inc./Empire Wound Care for Resident 1 (R1). Documentation dated 10/03/2025 indicated R1 had multiple wounds, including a Stage 4 pressure injury located at the center midline sacrococcyx with a duration of greater than two years and pre-debridement measurements of 4.6 cm x 8.6 cm x 0.4 cm. R1 also had a wound on the left medial second toe with a duration of six weeks and pre-debridement measurements of 0.7 cm x 0.5 cm x UTD. In addition, R1 had a Stage 3 pressure injury on the left posterior distal buttocks with a duration of four weeks and pre-debridement measurements of 3.1 cm x 2.5 cm x 0.1 cm, as well as a Stage 3 pressure injury on the right posterior distal buttocks with a duration of six weeks and pre-debridement measurements of 3.5 cm x 2.5 cm x 0.1 cm. On 10/10/2025, which indicated the center midline sacrococcyx wound remained at Stage 4 with pre-debridement measurements of 4.3 cm x 8.5 cm x 0.3 cm and post-debridement measurements of 4.4 cm x 8.6 cm x 0.4 cm. The left medial second toe wound remained at the same stage with a seven-week duration and pre-debridement measurements of 0.7 cm x 0.5 cm x UTD, with no post-debridement measurements documented. The left posterior distal buttocks wound remained Stage 3 with an eight-week duration and pre-debridement measurements of 3.1 cm x 2.3 cm x UTD and post-debridement measurements of 3.2 cm x 2.4 cm x 0.2 cm. The right posterior distal buttocks wound also remained Stage 3 with pre-debridement measurements of 3.4 cm x 2.5 cm x 0.05 cm, and no post-debridement measurements were documented. Further review of wound care documentation dated 10/17/2025, 10/24/2025, and 10/31/2025 indicated that all previously identified wounds remained at the same stage and with no significant changes in measurements. Documentation dated 10/24/2025 additionally noted a new wound located on the left lateral third finger with a duration of one week and measurements of 0.4 cm x 0.4 cm x 0.1 cm. Based on observation, LPA observed a repositioning chart posted in Resident 1’s room, which served as a reminder for staff regarding scheduled repositioning needs for R1. The Department interviewed the responsible party for R1, who stated they did not have any concerns regarding the allegations listed above. The Department also interviewed Witness 1, who stated they had no concerns regarding staff repositioning of Resident 1 or the cleaning and care of the resident’s wounds. Based on the information gathered, interviews, and record reviews, there is not enough evidence to support that Regency Palms Long Beach failed to provide proper care to Resident 1 resulting in pressure injures for the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not assist resident with obtaining medical care It was alleged that the resident teeth are rotting and the reporting party doesn't know if R1's is getting dental care. On 11/04/2025, between the hours of 11:25am - 11:45am , LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that depending on the resident's care plan, prompting and/or assistance is provided two times per day, as tolerated, for how often residents' teeth are brushed throughout the day. As it pertains to R1, the facility swabs their teeth, as the resident cannot safely swallow and is an aspiration risk. Additionally, R1's teeth show signs of decay consistent with her age and previous dental care. A1 stated the facility does not coordinate dental care for R1, as this matter is managed by the family. A1 also mentioned that at this point of R1's disease process, the resident could not receive dental care, as they could not get a dentist and R1 would not be able to survive the procedures. R1 is currently on hospice at the end of life, and comfort care is being administered per her Power of Attorney (POA). Report continues on LIC 9099-C On 11/04/2025, between the hours of 8:42am - 12:20pm, LPA interviewed 7 staff members regarding the allegation. 7 of 7 staff denied the allegation and stated the residents' teeth are brushed every shift in the morning/evening and after every meal. On 11/04/2025, between the hours of 9:09am - 10:47pm, LPA interviewed 6 resident interviews regarding the allegation. 6 of 6 residents denied the allegation and stated staff do not assist with brushing their teeth, as the residents independently brush their own teeth. 2 of 6 residents said they have not had any dental procedures conducted. 2 of 6 residents stated their family and/or friends assist with their dental care needs. 1 of 6 residents stated they wish to go to the dentist since they have not been to the dentist while living at the facility.1 of 6 residents stated they went to the dentist three months ago. On 12/22/2025 between the hours of 3:00pm - 4:30pm, LPA conducted a records review of R1's Service Plan (dated 07/25/2025) on page 2 of 8 which states under the dental section full assistance with oral care On 10/28/2025 at 2:45pm, the department interviewed the responsible party for R1 who stated arranging for a mobile dentist to visit since R1 who is bed bound. The responsible party for R1 also stated visiting the facility daily to ensure her teeth are brushed properly. Although R1's responsible party did express concerns via email with staff regard frequency of R1's teeth being brushed based on the information gathered, interviews, and record reviews, there is not enough evidence to support that Regency Palms Long Beach failed to provide proper care to Resident 1 in regards to teeth rotting for the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Robert Jakini (Administrator) and a copy of this report was provided