Complaint·October 28, 2021

approximately 4:09 pm and on 11/6/2020 between 12:21 pm and 2:05 pm revealed that in July 2020, R1 presented a pressure injury on their lower back and on their heels. Staff indicated that after interruption of home health care services, from 08/13/2020 to 08/27/2020 the wound care was provided by the facility staff. During the week of 08/24/20, the pressure injuries progressively worsened. A pressure injury on R1’s lower back quickly opened up to a pea/dime size hole giving a foul smell. On 08/27/2020, during medical appointment, the dressing from R1’s pressure injury was removed a white/yellow puss that was deep the size of the pinky fingertip was observed along with a foul smell. R1 was sent to the hospital the following morning of 08/28/2020. Home care records reviewed on 11/5/2020 revealed that on 07/22/2020 R1’s pressure injuries were assessed and documented. R1’s pressure injury on left hip was staged unstageable. A pressure injury on sacrum was staged a stage 4 and pressure injuries on left, and right heel were staged unstageable. R1’s hospital medical records reviewed on 10/13/2020 revealed that while in the hospital R1 presented with a stage 4 sacral decubitus ulcer that was later evaluated and diagnosed to be an infected unstageable sacral decubitus ulcer, that is fairly deep and appears to be clinically infected. Information revealed from the records is corroborating the information revealed from the interviews. Therefore, based on interviews and record review, the investigation the allegation is deemed substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Today, a $500 immediate civil penalty (LIC 421 IM-Civil Penalty assessment) is assessed due to a violation which resulted in R1 sustaining an injury. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview was conducted, today's reports, civil penalty and appeals rights were reviewed and emailed to the Administrator.