complaint·June 11, 2025

Continued from LIC9099... Per progress noted dated 03/14/2025, HM was verbally notified by R1’s PCP to begin monitoring, turning, and repositioning R1, at which time HM observed the pressure injury. Further interviews with R1 and Staff 1 (S1), revealed that the facility was aware of R1's discomfort and the injury that was forming for at least a week prior to R1’s wound being evaluated and staged by their PCP and that visit was initiated by R1’s family on March 19, 2025. On March 24, 2025, LPA received a copy of R1’s Doctor’s Orders indicating the pressure injury was a “stage 2” pressure injury. Based on interviews conducted and records reviewed, the facility was unable to provide proof of a medical assessment being sought for R1 in the time prior to the staging which resulted from the family’s efforts, (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit, (see LIC421IM). R1 was sent to the hospital for generalized weakness on 03/20/2025. At that time R1's family notified facility that R1 would not be returning. Based on interviews conducted and records obtained, the allegation that the facility did not seek timely medical for R1 is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). The House Manager was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). Exit interview conducted. Copy of report discussed and provided to House Manager, whose signature on form confirms receipt of documents. Appeal rights provided. Continued from LIC9099A... Further interviews with R1 and Staff 1 (S1), revealed that the facility was aware of R1's discomfort and the injury that was forming for at least a week prior to R1’s wound being evaluated and staged by their PCP and that visit was initiated by R1’s family on March 19, 2025. On March 24, 2025, LPA received a copy of R1’s Doctor’s Orders indicating the pressure injury was a “stage 2” pressure injury. Based on interviews and record review, the facility was unable to provide proof of a medical assessment being sought for R1 in the time prior to the staging which resulted from the family’s efforts. On 03/20/2025 R1 was sent to the hospital for generalized weakness. At that time R1's family notified the facility that R1 would not be returning. Based on interviews conducted and records reviewed, the department received conflicting information. Based on interviews conducted and records obtained, the allegation that the facility failed to observe change of condition for R1 is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents.