complaint·July 10, 2025

On 02/14/2024 home health services were initiated and record states that R1 developed a stage three pressure injury. On 04/04/2024 R1 was discharged from receiving home health services because the pressure injury has healed. On 10/15/2024, R1s home health services were renewed and was diagnosed with stage three pressure injury on the right heel, and stage one pressure injury on the sacral region. On 12/11/2024, R1 was discharged from home health services due to progressing pressure injury and was placed under hospice care. Based on interview of R1, R1 stated he/she does not care to be turned due to pain when moving. R1 refuses the booties given by staff to protect his/her heels and does not allow staff to put the booties on. Based on document review, facility staff informs R1s physicians when R1 refuses to be repositioned to prevent pressure injury. R1 is receiving palliative care daily for R1s wound and repositioning. Based on interviews with 5 staff (S1 to S5). 5 Out of 5 staff revealed consistent statements that R1 refused to be repositioned and refused any care to help heal the pressure injury. S3 stated he/she explained to R1 that R1 needs to be repositioned based on R1s care plan. Based on interviews with 5 witnesses (W1 to W5). W1 stated R1s health condition contributed to R1s pressure injury to worsen and R1 has a long history of refusing care. W1 stated, R1 is visited and cared for 5 times a week. W2 did not provide additional information. W3 stated that R1 refused to be re-hospitalized and wanted to stay in bed and R1 was non-compliant with ADL which led to progression of R1s wounds. Based on interviews, document reviews and investigations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation of neglect and lack of supervision causing R1 to develop pressure injury is UNSUBSTANTIATED, based on California Code of Regulation (CCR) Title 22. Page 2 of 3 Staff Mismanaging Medication On 7/10/2025, LPA Tarin reviewed R1's Medication Administration Record (MAR) for January through April 2025. LPA did not observe discrepancies for medications administered to R1 for the months of January through April 2025. LPA interviewed 2 staff (S6 and S7). 2 out of 2 staff stated R1 did not have any medications missing or misplaced during the months of January to April 2025. Based on document review, LPA observed all medications orders documented, with no reports of missing or misplaced medication Based on interviews with 5 witnesses (W1 to W5). W1 stated the facility 'misplaced' R1's medication in February 2025. W2 to W5 did not provide additional information. Based on interviews, document reviews and investigations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation of staff mismanaging R1's medication, and is UNSUBSTANTIATE D, based on California Code of Regulation (CCR) Title 22. No deficiencies are being cited during today's visit. An exit interview was conducted with ADM and a copy of this report was provided. Page 3 of 3. End of Report