complaint·August 20, 2025

Facility records reviewed did not indicate continuous observation nor care being provided for all conditions observed at hospital admission, in addition, staff interviews did not reveal consistent observation and care of these multiple conditions. In some cases, facility staff reported during interviews that they were unaware of one or more of R1’s wounds (pressure injuries). R1 was admitted to the facility on or around October 9, 2021. Records indicate that R1 was to be provided basic services at a minimum to include continuous care and supervision, observation for changes in physical, mental, emotional, and social functioning; and notification to R1 family, physician, and other appropriate person/agency of R1's needs. In addition, R1 was to be provided with assistance with personal activities of daily living including dressing, eating, toileting, bathing, grooming, mobility tasks. More specifically, R1 is described as non-ambulatory and requires a wheelchair for mobility, help with transferring in and out of bed, and incontinent care to be provided. When R1 was admitted to the facility, no pressure injuries were indicated in physician report nor pre-placement appraisal. From time period prior to and following admission, R1 was receiving home health services. The services included nurse visits, first documented in records to have occurred on November 16, 2021. During that visit, home health records indicate that closed wounds were assessed on buttocks. Plans were indicated for cleaning of area and rotating area every 2-4 hours to prevent pressure sore from developing. During a subsequent home health visit on November 23, 2021, two wounds were observed. One wound was identified in home health records as an unstageable pressure ulcer. According to records, facility staff were made aware of wound care plan and treatment, including pressure sore prevention, and instruction to have R1 repositioned as frequently as possible every 2-4 hours. Facility staff were also to put pillows under R1 back and not to cover coccyx/sacral area and to monitor potential pressure sore areas such as heels, elbows, shoulders, knees, back, Etc. As noted upon hospital admission on November 25, 2021 (two days later), R1 was observed with multiple pressure injuries to areas such as flank, scapular area, both heels, left ear, knee, and buttocks. Based on the investigation, there is preponderance of evidence to support that facility staff neglected R1. Specifically, it was found that from at least October 9, 2021, until November 25, 2021, facility staff did not ensure care and supervision to meet R1 needs. Per facility records, R1 was to be provided continuous care and supervision as well as assistance with activities of daily living, including mobility and incontinent care. However, during the time when R1 resided at facility, R1 sustained multiple pressure injuries. Facility records and staff interviews support that facility staff were not continuously providing care and supervision to R1 to meet their needs. More specifically, R1 was observed on November 23, 2021, with two wounds, but two days later, was hospitalized and observed to have multiple pressure injuries. Allegation of neglect/lack of care and supervision resulting in R1 sustaining multiple pressure injuries is substantiated. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to Facility Caregiver Yaritza Jarquen at the end of the visit . Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Yaritza Jarquen at the end of the visit.