Allegation: Staff retained a resident with a stage 4 pressure injury.

It was alleged that the resident in care developed a Stage 4 sacral pressure injury, multiple pressure injuries, skin tears, and a possible fungal infection while residing at the facility.

On September 29, 2025, the Department interviewed Residents R1, R2, R3, and R4 regarding the allegation. Three (3) out of the four (4) residents denied having pressure injuries and reported no concerns related to skin breakdown. One (1) resident reported having a bedsore but was unable to recall whether treatment was being provided.

On September 16, 2025, and September 29, 2025, the Department interviewed W1. W1 reported that the resident did not have any pressure injuries upon admission to the facility but had numerous chronic medical conditions and was receiving services from Hollywood Home Health. W1 stated there was never an indication that the facility was neglecting the resident; however, W1 expressed dissatisfaction with the wound care provider's treatment of the resident's wounds. W1 further reported that the facility did not inform them that the resident could no longer remain at the facility if the wound progressed to a prohibited condition.

On October 2, 2025, the Department interviewed W2. W2 stated that after reviewing home health nursing notes, W1 became aware that home health personnel had concerns regarding the wound care being provided. W2 further reported that the resident would likely have benefited from a higher level of care and believed the wound observed was consistent with a Stage 4 pressure injury despite being treated primarily with topical medication.

On October 8, 2025, the Department interviewed W3. W3 reported that the resident had previously been hospitalized in January 2025 and, at that time, a Stage 3 sacrococcygeal pressure injury had been identified. W3 stated that appropriate treatment and preventative measures following the hospitalization may have prevented further deterioration of the wound.

Records further showed that on August 27, 2025, a facility caregiver observed worsening of the resident's wound, photographed the area, and forwarded the images to the Durable Power of Attorney; however, neither the physician nor the home health agency was notified. Home health staff were not made aware of the wound deterioration until a subsequent visit on August 29, 2025.

On August 31, 2025, the sacrococcygeal wound was documented as having progressed to a Stage 4 pressure injury. On September 5, 2025, a wound care specialist identified a Stage 4 sacral pressure injury with necrosis and noted that the wound appeared inadequately treated. The specialist ordered repositioning every two hours, 24 hours per day, implementation of a low-air-loss mattress, and moisture-control measures.

The records review also revealed that although the facility employed live-in caregivers, staff were routinely off duty between 7:00 p.m. and 7:00 a.m., resulting in limited overnight repositioning and incontinence care. Additionally, there was no documentation demonstrating that the facility notified the resident's primary care physician regarding the resident's noncompliance with repositioning and offloading recommendations or the home health agency's failure to provide a low-air-loss mattress.

On September 9, 2025, the resident was transferred to the hospital due to shortness of breath and was admitted with sepsis and pleural effusion. Hospital wound assessments documented a Stage 4 sacrococcygeal pressure injury; Stage 3 pressure injuries involving the buttocks, hips, and left lower leg; full-thickness wounds beneath both breasts; and multiple skin tears to the upper extremities. The resident underwent surgical debridement, received intravenous antibiotics for sepsis and a positive sacral wound culture, and was subsequently discharged to Kindred Hospital on September 19, 2025.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D).

*Immediate Civil Penalty issued*

ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

Exit interview conducted with Myrna Ma (Licensee), appeal rights reviewed and a copy of this report was provided.

Also on October 30, 2025, the Department interviewed Staff S2 (S2) and Staff 3 (S3). Both staff members reported that the resident had no pressure injuries upon admission to the facility and was receiving wound care services from a nurse who was later replaced due to worsening wound conditions. Both staff members stated that they repositioned the resident every two hours, utilizing wedges as directed by home health; however, repositioning occurred only during waking hours. One staff member acknowledged being unaware of the stage at which a pressure injury becomes a prohibited condition.

On November 6, 2025, the Department interviewed A1. A1 stated that they recommended W1 change home health providers because the nurse was treating the wound primarily with antibiotic ointment. A1 further reported that facility caregivers communicated wound-related concerns directly to W1, who was in communication with the home health agency. A1 also stated they were unaware that Stage 3 and Stage 4 pressure injuries are considered prohibited conditions in a licensed facility.

On November 19, 2025, the Department interviewed W5. W5 reported that a family member previously resided at the facility and developed a Stage 4 pressure injury while receiving hospice or palliative care services. W5 stated that concerns regarding the quality of care provided at the facility ultimately resulted in the family member's relocation.

The Department conducted a review of facility, hospital, home health, and wound care records. Records revealed that the resident was admitted to the facility in November 2024 with a history of a brain abscess resulting in right-sided weakness and liver cirrhosis causing elevated ammonia levels. Due to these conditions, the resident was bedbound and required total assistance with activities of daily living.

Documentation indicated that following a hospitalization in January 2025, the resident returned to the facility with a Stage 2 pressure injury and ongoing home health services. Despite wound care interventions, caregiver education, and repeated instructions to reposition the resident every one to two hours, the wound progressively deteriorated. By May 2025, the pressure injury had advanced to Stage 3. In June 2025, records documented a Stage 3 sacrococcygeal pressure injury, with contributing factors identified as immobility, incontinence, and encephalopathy.