Complaint·November 6, 2025

It was alleged that staff did not take preventative measures to ensure resident does not sustain pressure injuries. LPA conducted staff interviews and review of records the allegation; Interview with a witness (W1), hospice resident (R1) was found to have multiple wounds and sores injuries. W1 stated that a hospice staff informed facility staff of some injuries were the result of R1’s being double diapered by facility staff. Interview with another witness (W2 ), confirmed that staff did take preventative measures to ensure resident does no however this was not the case in 2-3 occasions in which facility staff was double diapering R1 which could have resulted in pressure injuries and delayed healing. Record review of hospice records indicate a pressure ulcer was documented on 8/21/25 on right hip, 8/19/25 on left foot, 8/26/25 on lower right back, and on left thigh on 9/4/25 . Skin tears are noted. on 8/28/25 on right wrist and right knuckle and a blister on the tight waist. Hospice notes stated education was provided to facility staff on how to care for and off-load pressure areas. Interview with Administrator, S1 confirms hospice staff held a meeting with the facility to address double diapering of staff in which staff was instructed to no longer do so. S1 stated the staff member that was double diapering the resident is no longer working at the facility since April 2025. S1 and S2 confirm R1 did not have any pressure wounds prior to their admission to the facility, although the R1 had "sensitive skin". W2 stated that although total wound healing was not expected, one facility staff could have done more to prevent pressure injuries. S1 instructed care staff to start maintain progress notes for R1 per Long Term Care Ombudsman's recommendation. LPA reviewed progress notes for R1 from 8/26-9/5/25. Based on the observations of the LPA and review of records the allegation staff did not take preventative measures to ensure resident does not sustain pressure injuries is substantiated. It was alleged that resident sustained unexplained injuries while in care. LPA conducted staff interviews and review of records the allegation; LPA observed photographs of wounds sustained by R1 in the pinky knuckle of their hand, the side of their toe on their foot, and on their knee. W1 stated when facility staff asked what happened to R1 or how a certain skin tear occurred, Staff would respond "I don’t know". S2 stated they conducted body checks but there was no log, S2 would sometimes report observed wounds to family but not always due to hospice reporting to family already. CONTINUED ON 9099-D S1 and W2 stated R1 had very " fragile skin". W2 stated this meant it needed more care. W2 stated they advised that patients should not be sitting all day, as they lay down after meals to off-load pressure, but this was sometimes not done per family's request to not have R1 to be isolated in their room during the day. Hospice staff provided training on how to prevent pressure injuries but staff did not always follow thru completely with training guidelines including turning R1. Hospice staff was not full time, so facility care staff was responsible for the full time care. Based on the observations of the LPA and review of records the allegation resident sustained unexplained injuries while in care is substantiated. It was alleged that staff did not meet resident's diapering needs. LPA conducted staff interviews and review of records the allegation. W1 and W2 stated two diapers were observed on R1 on more than one occasion. The facility staff requested XL diapers even though R1 was not size XL. S1 and S2 stated they met with the hospice team to address double diapering not being allowed, as it was resulting in pressure injuries. A witness (W3) stated they saw blisters on thighs and inside of waist of R1. Per plan of operation and admissions agreements the facility agrees to provide “… routine observation, care and supervision, and personal assistance and care with their needs and activities of daily living. These needs are indicated by the results of the preadmission appraisal, family and resident interviews, physician consult, etc. Personal assistance and care includes dressing, grooming, eating, bathing and assistance with taking prescribed medications’”. Based on the interviews and review of records the allegation, staff did not meet resident's diapering needs, is substantiated. It was alleged that staff did not properly transfer resident's items to new facility.LPA conducted staff interviews and review of records the allegation. Based on interview with S2, they stated they put everything is in the boxes with everting they think R1 needed, in the "care-kit". S1 stated they told R1's family to check the room, in which they did but did not take anything additional. R1's daughter returned back to the facility due to diapers, toiletries, personal blanket, razors, dentures, and belongings that were not packed the first time. S2 stated they did not pack those items because they thought they didnt need them or where donations. R1's son requested R1's POLST, and S2 stated they did not have one. S1 stated R1 does have a POLST but S2 did not understand what a POLST was. CONTINUED ON 9099-C Per plan of operation: basic services provided include “assistance with bathing, dressing, grooming, toileting, eating, continence, transferring from bed or chair, and other personal needs”. LPA conduced records review and interviews. S1 stated the facility did not maintain a grooming log including shaving, nail maintenance, and showering schedules. S2 stated hospice staff and they were both in charge of grooming for R1. S2 and W2 stated R1's family member requested for staff the shave R1s beard by putting staff's fingers in R1's mouth to assist with shaving due to R1 not having any teeth, however care staff states this was not safe to do. Interview with two witnesses (W1 and W2) as well as one Staff (S1) confirm R1 did not have any teeth which made it "challenging" or "unsafe" to fully shave R1 often. S2 stated an electric razor was provided to the facility as it was requested, however. S2 reports R1 was not always "cooperative" and grooming attempts were attempted later on when R1 would be more "not combative"". Although R1 did not have teeth, "He tries to bite us" and "we will try again once the beard is a longer so its more do-able "Per department regulations it's a residents' personal right to refuse services at any time. Department has determined no violations were observed regarding grooming. Based on the observations of the LPA and review of records the allegation Staff did not ensure resident's grooming needs were being met is unsubstantiated. It was alleged staff mismanage resident's medications. LPA Tamayo Reviewed medications and medications records for R1- R5. R2- R5 did not have any discrepancy showing any evidence of mismanagement of resident's medications. S1, and S2 stated all medications were administered to R1-R5. W2 stated they did not witness any discrepancy with medications or any medication mismanagement by the facility staff. W1 and W3 stated there was one medication that was not administered to R1 on a daily basis to to low refills. R1 and or R1's family took all their medications and some medication records with them upon move out on 6/9/25. LPA Tamayo reviewed record keeping requirements with facility staff. LPA was not able to corroborate the allegation staff mismanage resident's medications. Although the allegations above may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff and a copy of this report was left at the facility. S1 confirmed a copy of the POLST was available to the R1's authorized representative at move out. Based on the observations of the LPA and review of records the allegation, staff did not properly transfer resident's items to new facility, is substantiated. It was alleged that Staff did not notify resident's responsible party of incidents. LPA conducted staff interviews and review of records the allegation. Interview with S1 confirms staff tired notify resident's responsible party of incidents, but did not always do so. S1 had staff start to maintain 'progress notes" to serve as reporting as of 8/26/25 but there was no other reporting verification available to families before 8/26/25. S1 stated there is sometimes a language barrier between S2 and families and S2's word choice "could be better". S1 and S2 stated S2 could have been more consistent with ensuring better with S1 and responsible parties. S2 was instructed to notify S1 of any type of injuries or incidents that involved residents so S2 can communicate with families but S2 did not always do so. Based on the observations of the LPA and review of records the allegation, staff did not notify resident's responsible party of incidents is, substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Peti and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.