Complaint·March 19, 2026

On or about 1-4-2025, R1 was sent back to and accepted by facility for re-admission. Additional documentation review did not reveal facility follow up or other sufficient outside intervention for the stage 3 wound. On 1-28-2025, hospital notes revealed that R1 was received at hospital on this date with diagnosis of “severe sepsis most likely secondary to sacral decubiti.” According to pms.ncbi.nlm.nih.gov, a “sacral decubiti (pressure ulcers) are localized damage to the skin and underlying soft tissue over the tailbone, cause by prolonged pressure, friction, or shear…” Facility care notes state R1 was later discharged back to facility on 1-31-2025 with plans for hospice care. R1 passed away on 3-27-2025. Based on evidence reviewed, there is a preponderance of evidence to conclude that resident experienced a worsening condition of a wound within facility leading to a stage 3 wound and related diagnosis of sepsis. As a result, the above allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Health and Safety Codes. Failure to correct the deficiency may result in additional civil penalties. An immediate civil penalty in the amount of five-hundred dollars ($500) was issued in addition to citation due to a violation resulting in a severe injury. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with S2, and a copy of this report was provided. Administrator was made aware of findings via phone call as she was off site. Appeal rights provided. LIC 811 provided.