complaint·February 4, 2026

There are no facility records or home health records for the time period from October 14 to November 17, 2022. It is unclear how R1 developed a stage 3 pressure injury in that time but staff should have been aware of the injury before it developed to a stage 3 injury which required wound care. Home health was ordered for R1 and wound care provided to R1 beginning November 19, 2022. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. The investigation into the allegation, Resident is left in a soiled diaper for an extended period sustaining lesions, revealed the following. It was reported that Resident 1 (R1) sustained a pressure injury on their buttock. R1’s physician report dated October 14, 2022, did not have any mention of pressure injuries or skin issues. A review of hospice records shows that R1 was diagnosed with a stage 3 pressure injury on their left heel on November 19, 2022. R1 was diagnosed with stage 2 pressure injury on their coccyx on December 17, 2022. 1 out of 3 staff interviewed reported that R1 was regularly put in 2 briefs because they couldn’t always be changed quickly. Staff 1 reported that this practice was stopped because hospice requested them to stop. R1 was not always changed timely and developed a new pressure injury around a month after their first pressure injury was diagnosed. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.