Complaint·May 15, 2026

...... CONTINUE from LIC9099 The investigation revealed the following: Regarding the allegation, Resident developed pressure injuries due to lack of care and supervision , the investigation is as follows: On August 18, 2025, R1 was found to have a stage 3 pressure injury on the coccyx, measuring 3cm x 4 cm x 0.3 cm; a linear ulceration on the left posterior thigh (probably friction and moisture related), measuring 0.5cm x 7cm x 0.2cm, and an unstageable pressure injury on his right heel, measuring 3cm x 4cm x unknown depth. The facility first noted an open wound on R1’s right heel and a pressure injury on his coccyx on August 11, 2025. During interviews, facility caregivers admitted that they were not repositioning R1 in his wheelchair and that the wounds were likely the result of continuous sitting on the wheelchair with his heel pressed against the footrest or floor. On August 13, 2025, R1’s coccyx pressure injury was documented at stage 2, measuring 5.2cm x 1.3cm, but measurements for the heel wound were not documented. The facility only arranged for R1’s hospitalization for assessment after his daughter/Power Of Attorney (POA) requested it, but by this time, the wounds had progressed to greater than stage 2. On August 18, 2025, R1 was admitted to Kaiser Anaheim Hospital due to multiple newly discovered pressure injuries that were not reported to his POA. Based on staff admissions, following the discovery of these wounds, R1 continued being placed in his wheelchair, at his request, but was not being repositioned in it. The allegation that R1 sustained stage 3 and unstageable pressure injuries because of facility neglect is therefore Substantiated. Regarding the allegation, facility did not seek medical attention in a timely manner, the facility was aware at least one full week before R1’s hospitalization, that resident had developed pressure injuries. Based on records obtained, Staff 1 (S1) was the first caregiver to document a “blister” on R1’s right heel, which was observed while providing R1 a bed bath on August 11, 2025. Per progress notes, Staff 2 (S2) documented on the progress notes that S1 reported having observed an “open wound” on R1’s right heel while providing a bed bath. CONTINUE TO LIC9099-C........ S2 observed fluid leakage from R1’s legs and increased swelling to both feet, with the skin of both feet “very dry and cracking.” S2 elevated R1’s legs to reduce the swelling and planned to continue monitoring the resident’s skin condition and reporting changes. S2 notified home health of the open wound via fax and called the office of his Primary Care Physician (PCP) about the “open blister.” Records reviewed indicate the facility faxed PCP’s office to report that R1’s legs are more swollen than usual and leaving fluid and faxed Excell Home Care (Home Health) to report an “open wound on R1’s right heel, about a quarter size.” R1 complained of pain and discomfort when applying pressure. The facility requested for the Home Health to send a nurse to check the wound as soon as possible. On August 12, 2025, Staff 3 (S3) noted that Excell Home Care would visit R1 on August 13, 2025. Staff 4 (S4) documented on August 13, 2025 that she spoke with POA to request softer/looser shorts to prevent friction and tightness in R1’s buttocks due to “skin peeling.” S4 also called the PCP’s office to request assessment of this skin peeling. Later that day, S3 noted their belief that Home Health had not visited R1 as arranged, and requested that a follow up be done. On August 14, 2025, while providing a sponge bath, Staff 6 (S6) documented on Shower Sheets redness and “peeling skin” to R1’s buttocks area and an “open blister” on the right heel. On August 15, 2025, R1 was placed on alert charting for 72 hours due to complaints of leg pain. Later that day, Staff 6 (S6) called R1’s PCP’s office to request Home Health wound care “for bedsores on the buttocks and pressure bedsore on the left heel.” S5 applied Calmoseptine on R1’s buttocks, put him in bed after lunch, and elevated his legs. On August 16, 2025, S6 again applied Calmoseptine to R1’s “private area” and placed a patch on his heel. The facility was aware on August 11, 2025, one full week before R1’s hospitalization, that he had developed pressure injuries. Although the facility notified Excell Home Care (Home Health) of the change in condition in a timely manner, it failed to ensure R1 received treatment. The facility did not inquire with Home Health about the progression of the wounds, had no documentation of treatment as required by 22 CCR § 87631, was not aware appointments were being cancelled due to R1’s purported refusals and failure to respond to agency calls, and did not even know whether home health was providing treatment. Home Health did not visit R1 between July 26, 2025 and August 12, 2025; and while the Home Health did treat the coccyx wound on August 13, 2025, this was the last time treatment was provided, and it never treated the right heel wound. The facility only arranged for R1’s hospitalization for assessment after his POA requested it, but by this time, the wounds had progressed to greater than stage 2. The allegation that the facility failed to ensure R1 received timely medical attention for his pressure injuries is therefore Substantiated. CONTINUE TO LIC9099-C........ Regarding the allegation , Facility did not notify family regarding pressure injuries. On August 18, 2025, around 3:00pm, S2 called Daughter/Power Of Attorney (POA) and informed them that the facility was trying to get a hold of R1’s doctor to get medicine for pressure injuries, explaining that the wounds were on R1’s foot, buttocks, and inner thigh. After reviewing pictures received by staff, the POA asked the facility to send R1 to Kaiser Anaheim Hospital. A Kaiser physician called POA to report that the pressure injuries were at stage 3. On August 19, 2025 Witness 1 (W1) submitted a SOC341 to The Department to report that R1 was admitted to Kaiser Anaheim Hospital on August 18, 2025 due to multiple newly discovered pressure injuries that were not reported to his daughter/POA. It was reported that during visits with family, R1 wore “diabetic shoes,” and the POA never saw the resident’s exposed feet, but the facility bathed R1 at least twice a week and also changed his clothes daily. Although the facility first became aware of the pressure injuries on August 11, 2025, the POA was not aware until August 18, 2025, prior to requesting R1 be sent to the hospital. Therefore, the allegation that the facility did not notify family regarding pressure injuries is deemed Substantiated. Therefore, based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Resident developed pressure injuries due to lack of care and supervision, facility did not seek medical attention in a timely manner, and Facility did not notify family regarding pressure injuries are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC 9099Ds, as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC 9099-Ds, LIC 811, and appeal rights were provided at exit.