complaint·March 6, 2026

During the investigation LPA reviewed documents including the Allied Hospice Care, Inc. Plan of Care dated July 15, 2024, for R1. Per Plan of Care, R1 was admitted to Hospice on July 2, 2024. Per Plan of Care, on November 4, 2024, Hospice services were discontinued for R1. LPA reviewed the Hoag Memorial Hospital Admission records dated November 28, 2024, for R1. Per Admission records, R1 was admitted to the Hospital on November 28, 2024. Per Admission records, R1 was admitted to the Hospital for multiple pressure injuries present on admission: Coccyx – unstageable; left hip – stage 2; left foot and left ankle – stage 2, all of which required wound care treatment. LPA reviewed the Program Clinical Consultant’s (PCC) Report dated December 4, 2025, for R1. Per PCC, following R1’s Hospice discontinuation on November 4, 2024, the facility assumed full responsibility for the R1’s ongoing care without Hospice support. Per PCC, during this post-hospice period, the facility did not implement preventive skin measures, nor conduct routine skin monitoring/assessment. Per PCC, the timeline supports the evidence that pressure injuries developed during a period of insufficient preventive care and delayed medical intervention following Hospice discharge and/or days leading to R1’s hospitalization on November 28, 2024. Despite R1’s non-ambulatory status, full dependence on Activities of Daily Living (ADLs), incontinence care, and poor nutritional intake, there was no documented evidence regarding an updated individualized care plan and/or a routine repositioning protocol. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. The facility is cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC9099-D, and Appeal Rights were provided. An exit interview was conducted with facility representative, and a copy of this report was left at the facility.