complaint·December 16, 2024

Resident R1 reported that facility staff were not repositioning her every two hours as instructed by PIH Home Health. Per Preplacement Appraisal, Resident R1 had a stage 2 bed sore at the time of admission into the facility. Facility administration and staff knew Resident R1 had a pressure wound because Resident R1 was admitted to the facility with a stage 2 pressure ulcer. Resident R1's pressure ulcers progressively worsened to a stage 4 on 11/6/2023, and small drainage was noted. On 11/10/2023, Resident R1's pressure ulcer was unstageable. Resident R1 was admitted into hospice on 3/7/2024, it was noted that Resident R1 had a stage 4 pressure ulcer in the coccyx and a stage 3 pressure ulcer in the sacral region. Per PIH Home Health medical records, staff S1 told the home health nurse to leave and that caregivers would do Resident R1's care. Staff S2 described R1's wounds as a deep hole that was red. Facility staff knew Resident R1 needed to be rotated every two hours and saw her wounds worsening however it is more likely than not that Resident R1 was not rotated every two hours, as instructed by Resident R1's medical team. PIH Home Health and Eden Hospice noted Resident R1's pain complaints. The facility failed to take appropriate actions to prevent Resident R1's pressure wounds from worsening; therefore, the allegation is substantiated. Based on observations and interviews which were conducted and record review, 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 6 are being cited on the attached LIC 9099D. Civil Penalty Assessed $500. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49 (e) Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted .