complaint·October 25, 2023

R4 was sent to hospital on 5/31/23 and returned to the facility on 6/1/23 and the pressure wound was assessed to stage 2. Based on an interview with Staff_1 (S1), there was no evidence between 5/25/23 and 5/31/23 to address the care of R4’s pressure wound. Based on record review and interview with S1, there was no evidence to indicate adequate care and monitoring was provided to the R4’s wound between 6/1/23 and 6/8/23. Based on record review, Home Health Agency assessed R4’s pressure wound to stage 3 on 6/7/23. Based on review of R4’s ADL notes, facility staff performed bed mobility for R4 daily; however, there is no specific documentation regarding the care and monitoring of R4’s pressure wound. During an interview with S1, LPAs requested additional evidence (including documentation) that address wound care, monitoring and progress of R4; however, S1 indicated that S1 does not have evidence to provide. Based on records review, and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, citations for deficiencies can be found on the LIC 9099 -D. An immediate civil penalty of $1000 is issued in addition to citation due to injury related to violation of Section 1569.312(e) due to repeat violation. Failure to correct deficiencies may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was held with administrator Caleb Summerhays, and a copy of this report and the appeal rights were provided.