complaint·April 9, 2025

progressed to stage four, requiring hospice intervention. Hospice records indicated severe tissue breakdown, with a portion of the wound being unstageable due to necrosis and surrounding non- blanching purple skin, further confirming a lack of adequate care. Based on staff interviews S1 stated that R1 did not have pressure sores upon admission but developed one approximately a month before discharge. S1 observed that wound dressing changes were not done frequently enough, and staff were not consistently repositioning R1 every two hours as required. S1 and S2 reported that caregivers were not responsible for wound care, and wound dressing changes were supposed to be conducted by Med Techs or home health nurses. However, dressing changes were observed to be inadequate, with S2 specifically noting that the dressing was sometimes soaking wet, indicating prolonged exposure to moisture and lack of timely intervention. S2 and S3 confirmed that R1 was not always repositioned every two hours, with gaps of up to five hours between changes. S2 further corroborated that the pressure sore worsened significantly within a week, indicating an accelerated deterioration due to lack of preventive care. According to S4 and S2 the facility had protocols for room checks every two hours and documentation of skin integrity issues. However, no facility records were provided to demonstrate consistent adherence to these protocols for R1. Staff interviews revealed staff shortages, with only one or two caregivers present at times, which impacted R1's care. Despite S2 stating that staff were advised to reposition R1 every two hours and place pillows to offload pressure, interviews with multiple staff members revealed inconsistent compliance, leading to the worsening of the wound. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Regarding Hygiene needs being met, again, staff related that R1 was very stiff/rigid physically, and movement appeared to cause pain/distress. Staff stated that a nurse from outside agency (wound care/hospice) was working with R1 and was reportedly bathing/cleaning R1 several times a week; but it's not clear if it was adequate. Staff related that they would clean R1 also. It appears that facility staff attempted to keep R1's hygiene needs met, but due to stiffness, pain, and wounds, it was difficult to move R1 around to provide hygiene. At this point it is not possible to say whether better care could have been provided given all the circumstances; or whether there was actually any neglect on the part of staff. Allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.