Complaint Investigation Report

that required a higher level of care. W1 stated that R1 has prohibited health condition, and the staff were not trained in how to assist R1 with the condition when needed. R1 was admitted to the facility 01/01/2025. The prohibited health condition that R1 has requires the facility to request an exception prior to admission, however, the facility did not submit a request for the exception. R1 was admitted into hospice services on 4/30/2025. R1 expired on 9/4/2025.

Allegation: Resident sustained a pressure injury due to staff neglect.

During the initial interview W1 stated resident sustained a pressure injury due to staff neglect. W1 stated R1 had a wound on her finger and one on her foot. W1 was unsure if the facility staff was trained how to position R1. During interview on 10/14/2025, both S1 and S2 stated that R1 had a wound on her left heel. S1 stated pillows were placed near bottom of R1's body due to her diagnosis. LPA did not observe any documentation that facility contacted any medical professional regarding wounds.

Based on interviews which were conducted, record review, and observation the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.