Complaint Investigation Report

progressed to stage four, requiring hospice intervention. Hospice records indicated severe tissue breakdown, with a portion of the wound being unstageable due to necrosis and surrounding non- blanching purple skin, further confirming a lack of adequate care.

Based on staff interviews S1 stated that R1 did not have pressure sores upon admission but

developed one approximately a month before discharge. S1 observed that wound dressing changes were

not done frequently enough, and staff were not consistently repositioning R1 every two hours as

required. S1 and S2 reported that caregivers were not responsible for wound care, and wound

dressing changes were supposed to be conducted by Med Techs or home health nurses. However,

dressing changes were observed to be inadequate, with S2 specifically noting that the dressing was

sometimes soaking wet, indicating prolonged exposure to moisture and lack of timely intervention.

S2 and S3 confirmed that R1 was not always repositioned every two hours, with gaps of up to five

hours between changes. S2 further corroborated that the pressure sore worsened significantly within

a week, indicating an accelerated deterioration due to lack of preventive care. According to S4 and

S2 the facility had protocols for room checks every two hours and documentation of skin integrity

However, no facility records were provided to demonstrate consistent adherence to these protocols

for R1. Staff interviews revealed staff shortages, with only one or two caregivers present at times, which impacted R1's care. Despite S2 stating that staff were advised to reposition R1 every two hours and place pillows to offload pressure, interviews with multiple staff members revealed inconsistent compliance, leading

Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.