Complaint·November 5, 2025

On 3/16/25, a nurse from Sutter Care Home came to assess R1 for the appropriate services that's required for R1's needs. Based on the nurse's assessment from Sutter Care, R1 was admitted to hospice on 3/22/25. R1's responsible party revoked hospice services on 4/6/25. Starting 4/1/25, home health started visiting R1 for physical therapy and continued to come 1-2x a week for leg exercises. Based on R1's progress notes reviewed, on 5/9/25, the facility observed an open wound on R1's sacrum. The facility notified R1's physician and the physician ordered home health to evaluate R1's wound. On 5/14/25, R1 was assessed by Sutter Care at Home who indicated that R1 had a pressure ulcer to sacrum. According to staff interviewed, the facility notified R1's physician, responsible party, and updated R1's care plan. Based on R1's care plan, the facility repositioned R1 every two hours, followed the treatment plan that was provided by home health, and monitored R1 for any changes of condition. In addition, home health was coming 2-3x a week for wound care. Based on the repositioning log, R1 was being repositioned every two hours. According to interviews conducted, med-techs were instructed to call hospice when R1's dressing needed to be changed or was soiled if the facility LVN was not present at the facility. In addition, according to the administrator, R1 had a one-on-one caregiver 24/7 who was also trained to change R1's dressing. Regarding the allegation, staff retained a resident with a prohibited health condition, according to the reporting party, on 5/14/25, R1 was found to have an open stage IV sacral pressure wound. During the investigation, LPA interviewed the administrator and reviewed R1’s file. According to documents reviewed, on 5/23/25, a wound nurse came to visit R1 and determined R1's sacral wound was unstageable. According to the Department's and facility's records reviewed, after the administrator was notified that the sacrum pressure injury was unstageable on 5/23/25, an exception request was submitted to Community Care Licensing the same day to request for the facility to continue providing care to R1 who had a prohibited health condition. Regarding the allegation, staff did not notify authorized representative of change in condition, on May 14, 2025, it was found that R1 had pressure wounds on his/her feet and an open stage IV sacral pressure wound, however R1’s authorized representative was not notified about the wound until May 21, 2025. (Continue to 9099C) During the investigation, LPA interviewed the administrator, reviewed home health notes, R1's charting notes, progress notes, and service plan. Based on home health document dated 5/14/25, R1 was observed to have a pressure ulcer to the sacrum. According to the administrator and service plan reviewed dated 5/14/25, the LVN updated the service plan due to change of condition, in specific to active pressure ulcer on heel and sacrum. Based on the progress reports and charting notes reviewed, R1's responsible party was contacted on 5/16/25 regarding the presence of the sacral wound. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.