complaint·March 18, 2026

On October 26, 2024, R1 was hospitalized due to difficulty breathing. Per interview with R1’s Responsible Party, Responsible Party was unaware of any special diet R1 may have been on. R1’s responsible party stated that R1 was still eating and swallowing towards the end of their time at the facility and had no concerns with aspiration. During the course of the investigation the Department conducted interviews. During interviews with AD & Staff #1 (S1), it was revealed that R1 had no dietary restrictions that either were aware of. S1 informed LPA that R1 was able to eat all the food that was provided just fine with staff assistance. LPA was unable to interview R1 at the time of the investigation. Based on observation, interviews, records reviewed, and information gathered during the investigation the preponderance of evidence standard has not been met, therefore the above allegation is deemed UNFOUNDED. Meaning the allegation facility is not adhering to resident’s dietary needs was false, could not have happened and/or is without a reasonable basis. The Department therefore dismissed the complaint. An exit interview was conducted and a copy of this report was left at the facility. The Department reviewed Hospital medical records for R1 dated October 26, 2024, through November 2, 2024. The records revealed the following: Upon admission, R1 was diagnosed with sepsis, pneumonia, bacteremia and a urinary tract infection. A pressure injury was found on R1’s coccyx and was diagnosed to be a stage 4 pressure wound that required daily wound care and dressing changes with repositioning every 2 hours. Per hospital staff notations, the family was aware of the pressure injury prior to hospitalization of R1 and reported that a physician assistant was coming to treat the wound. During the Department’s interview with R1’s Responsible Party it was revealed that they knew about a wound and felt it was due to the resident being bedridden. Interviews with staff #1 (S1) revealed that they would help treat and dress R1’s pressure injury themselves. No skilled professional was found to be treating R1’s pressure injury while in care at the facility. During interviews with the staff #2 (S2) it was revealed that R1 was on hospice when R1 first arrived at the facility but was discharged and had not been readmitted. Hospice discharge summary dated July 29, 2019, did not indicate R1 had any pressure injuries at the time of discharge. A review of facility records revealed no documentation of R1’s wound or pressure injury prevention measures for R1 such as notations of repositioning, incontinence care and skin integratory reports. Hospital discharge summary notes that R1 was transitioned to inpatient hospice care on October 30, 2024. On October 31, 2024, wound culture results revealed that there was a presence of bacterial growth in the pressure wound. R1 later passed away at the hospital on November 2, 2024. Based on interviews conducted, record review and information gathered during the investigation, the facility failed to address resident’s care needs resulting in an untreated pressure injury. Therefore, the preponderance of evidence standard has been met, the allegation Resident sustained a pressure injury while in facility care due to neglect is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e). An exit interview was conducted and a copy of this report, LIC9099-D, confidential names list and appeal rights were left at the facility.