complaint·February 11, 2026

On February 2, 2024, a referral to wound care was submitted and R1 was accepted into wound care on February 7, 2024. R1 was still on hospice to manage their comorbidities . R1 was visited by a wound care nurse once a week from February 7, 2024, to May 2, 2024. Records were requested for the visit that should of took place on May 9, 2024, but none were provided. A review of records shows the wound progressed from stage 2 to stage 3 and then unstageable and increased in size. On February 29, March 7, April 11, April 18 the wound was listed as improving, but overall, the wound increased in size and on April 26, 2024, the wound was diagnosed as infected. On May 18, 2024, the responsible party requested R1 be transferred to the hospital because the wound was not healing. R1 was diagnosed with a wound on December 24, 2023. Under hospice care the wound did not improve and wound care was ordered and approved. Under wound care the wound did not heal, increased in size and finally became infected and R1 was sent to the hospital due to the wound. Even though the staff rotated R1 as directed by hospice and wound care, R1’s wound never improved at the facility. It is unknown how often the wound was cleaned and bandages changed. A review of the photographic evidence shows the wound increased in size from February 2, 2024, to May 2, 2024. After 2 months of treatment the wound did not improve and increased in size, the resident remained at the facility and no changes to R1's plan care were made. The resident was on hospice but none of the notes show the resident was having any issues with their primary diagnosis of Parkinson Disease. On May 18, 2024, the resident was transported to the hospital at the request of the responsible party. The responsible party reported that once they notified the primary care physician of the situation they recommended R1 be transferred to the hospital. Facility staff reported that they were informed that R1 was being transferred to the hospital. After R1 was transferred it is unknown what happened to R1. R1’s responsible party did not respond to requests for an interview after May 28, 2024. The hospice nurse listed in the hospice records did not respond to requests for an interview. The wound care nurse interviewed had no direct knowledge of Resident 1 but assisted in providing the records. Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights were discussed with and provided to facility representative.