complaint·January 16, 2025

On 08/09/2024 it was documented in Resident #1 (R1s) medical records that there was no pressure injury on R1. On 09/16/2024, R1 moved into the facility. Staff #1 (S1) stated that when R1 arrived at the facility they had no open pressure injuries. On 10/01/2024, facility staff had reported to Home Health staff that R1 had developed pressure injuries. On 10/02/2024 R1s pressure injuries were assessed by Home Health staff and it was noted that R1 had two (2) stage three pressures injuries in their sacral region. One pressure injury was four centimeters by two centimeters and the other was five centimeters by two centimeters. Per Home Health facility staff was instructed to reposition R1 every one to two hours. On 10/06/2024 R1 was admitted to the hospital. While at the hospital, it was documented that R1 had a pressure injury that was eight centimeters by six centimeters. Interview with R1 indicated that they would lay in bed for four or more hours without being repositioned. R1 stated when they were repositioned, staff were rough with them. Interviews with staff revealed R1 needed to be repositioned every two to four hours. Two out of three staff were unaware of R1s injuries. Based on the information obtained, the facility did not meet R1’s needs resulting in R1 developing pressure injuries while in care, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22 regulations, Division 6, are being cited on the attached LIC 9099D Exit interview conducted and a copy of the report and appeal rights were left at the facility.