Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation “Staff did not prevent resident from developing a pressure injury”, it is being alleged that a resident (R1) was admitted on 10/25/25, with a stage 3 or greater Sacral Gluteal wound with necrotic tissue due to staff neglect. Record reviews revealed that on 10/29/25 R1 was being provided hospice services by Loyalty Hospice Services, Inc. On 11/01/25 R1 was admitted to Los Palos Post-Acute Care Center and was receiving Physical Therapy and Occupational Therapy and that R1 responded well to skilled services. On 05/12/25 LPA observed staff responding to requests from five (5) residents and two (2) family members visiting with their responsible person(s). Interviews revealed that two (2) out of three (3) staff were unfamiliar with R1, while one (1) out of three (3) staff disagreed with the allegation. One (1) family witness (W1) and one (1) hospice nurse (W2), along with two (2) out of two (2) residents, disagreed with the allegation. Based on observation, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with staff one, Ethel Monterroso - Licensee (S1), and a copy of this report has been provided.