Complaint Investigation Report

Regarding allegation: Resident developed multiple pressure injuries in care due to staff neglect.

It is alleged that on 2.17.2026 R1 had an appointment with their Geriatrician and R1 has several stage 3 wounds. R1 was admitted to the facility on 5.23.2025, record review, appraisal needs and service plan and preplacement appraisal (LIC 603), revealed that R1 did have an unstageable wound on their coccyx. All of the residents interviewed during the investigation did not address any concerns regarding their care at the facility. Hospital medical records reviewed reveal R1 had developed pressure injuries on their coccyx, sacral, and bilateral heel. Wound started developing on 4.14.2025 before R1 was admitted to the facility. An interview with staff revealed repositioning assistance was provided to avoid and give relief to pressure injuries by staff. Interview with R1’s family revealed that they are happy with the care given by the facility and were not aware that R1 required higher level of care.

Records reviewed reveal that all of the staff are trained and were following home health instructions on how to care for R1’s wounds. A review of hospital medical records revealed R1 was admitted to home health on 5.29.2025. On 5.29.2025 sacral wound stage 3 was noted measuring 1.5 cm x 1 cm x 0.2 cm. On 8.7.2025 medical records noted coccyx wound was noted as stage 2. Family refused to admit R1 to hospice. On 11.3.2025, additional wounds were noted to the right heel (full thickness skin loss) stage 3 measuring 2.25 cm x 2.5 cm x 0.2 cm; R1 was then admitted to hospice on 11.3.2025. On 2.5.2026, it was noted that R1 had stage 3 wounds on their right (R) heel measuring 2.25 cm x 2.5 cm x 0.2 cm. On 2.18.2026 right heel was noted as unstageable. Although R1 was receiving home health care and hospice care, staff were providing required assistance, pressure injuries were not healing and developed into unstageable wounds. Facility staff retained and accepted R1 from 5.23.2025 to 2.20.2026 with a stage 3 wound. Therefore, the allegation is substantiated .

Based on observation, interviews, and record review, there is sufficient evidence. Therefore, the allegation is deemed substantiated California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

An immediate Civil Penalty of $500.00 will be issued during this visit due to neglect/lack of care by providing care to R1 with a prohibited health condition. An additional civil penalty may be assessed at a later time based on Health and Safety Code 1569.49.

An exit interview was conducted. Appeal rights, a copy of the report, LIC 9099D, were provided.