It is alleged that Resident #1 (R1) developed a pressure injury due to staff negligence. It was reported that R1 has contracted pressure ulcers and has been scratching the tailbone. No further information is available or provided.

Resident #1 (R1) was admitted to Carson Senior Assisted Living on February 17, 2020, according to the Identification and Emergency Information (LIC 601, dated 02/17/25). On July 11, 2025, (R1) was hospitalized at Harbor UCLA Medical Center for septic shock. During the medical assessment, it was discovered that (R1) had a left trochanteric pressure ulcer, classified as Stage II, which had deteriorated, increasing in size and depth. Additionally, there was a left ischial ulcer that remained unchanged at the time, along with a deep tissue pressure injury (DTPI) to the sacrococcygeal area that also deteriorated, presenting a non-blanching wound bed and a boggy texture upon touch.

On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed staff members identified as Staff # 1 through Staff #5 (S1-S5). One (1) out of the five (5) staff members was able to verify by observation that (R1) had some skin blister and that staff were applying ointment on the blister for any skin condition. Four out of the five (5) claimed to have never observed any pressure injuries on (R1). All five staff members unanimously confirmed that (R1) was hospitalized on July 11, 2025, due to a significant decline in health, and importantly, were not receiving any home health or hospice care at that time.

On September 18, 2025, at 10:19 AM, the Department interview witness identified as Witness #1 (W1). (W1) was informed that (R1) was taken to Harbor UCLA for low blood pressure, dehydration, and bed sores. Later, (R1) was transferred to Kaiser Permanente and passed away on July 20, 2025. (W1) noted that (R1) did not receive home health or hospice care while at the facility.

The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025.

The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks.

(Evaluation Report continues LIC 9099-C)

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation #3: Staff did not seek timely medical attention for resident in care.

It is alleged that the staff failed to seek timely medical attention for Resident #1 (R1). Reports indicate that the facility neglected (R1), who was taken to the Harbor UCLA Medical Center emergency department due to concerns about low blood pressure and poor food intake. Upon assessment, (R1) was found to have low sodium levels, dehydration, and a pressure ulcer above the tailbone. It was reported that (R1) had been eating adequately in March 2025, and that the staff had not been notified about the bedsores. No further information is available or provided.

On October 6, 2025, between 11:16 AM and 12:14 PM, the Department interviewed a staff member, Staff #1 (S1). According to (S1), staff checked (R1)'s vitals, which showed low blood pressure, prompting them to contact 9-1-1. (R1) was transported to Harbor UCLA, where a deteriorating left trochanter Stage II pressure injury was discovered, showing an increase in size and coloration. Additionally, there was an unstageable left ischium injury that remained unchanged at the time, and an evolved Deep Tissue Pressure Injury (DPTPI) to the sacrococcygeal area that had also deteriorated, presenting a non-blanching wound bed that felt boggy to the touch.

(R1) was later transferred to Kaiser Permanente and passed away at the hospital on July 20, 2025. According to facility staff, (1) out of (5) staff members observed that (R1) had a skin blister and that staff were applying ointment to address the condition. However, (4) out of (5) staff members reported never having observed any pressure injuries on (R1) and (2) out of the (5) staff members recognized a change in mental and physical change in condition. Nevertheless, the facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks.

(Evaluation Report continues LIC 9099--C)

The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025.

The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), which indicated a history of skin conditions and breakdowns. The facility's charting notes documented a body assessment showing that on 07/09/25, (R1) had a skin tear in the left lower buttocks. On 07/10/25, the evaluation noted blisters and a skin tear on the left hip and continued breakdown in the lower buttocks. By 07/11/25, R1 was again noted to have skin breakdown.

Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, with (10) of those having side effects that could lead to skin rashes, itchy blisters, skin reactions, or peeling, which may potentially result in pressure injuries (ref: National Institutes of Health). Records from Harbor UCLA Medical Center indicated that (R1) had a decline in eating habits, low sodium levels, dehydration, and bed sores.

Based on the information gathered, there is sufficient evidence to support the allegations mentioned above.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation are found to be SUBSTANTIATED.

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

An exit interview was conducted with Melissa Serafin, and copies of the report and appeal rights were provided.

*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)

Allegation #2: Staff are not meeting resident’s dietary needs.

It is alleged that Resident #1 (R1) dietary needs were not met. It was reported that (R1) was brought to Harbor UCLA Medical center for low-blood pressure and sudden changes in eating patterns. It is reported that facility has been providing/attempting to provide liquid nutrition to patient since development of poor food intake. No further information is available or provided.

On October 6, 2025, and December 15, 2025, between 11:16 AM and 03:20 PM, the Department interviewed staff member identified as Staff #1 through Staff #6 (S1- S6). Two (2) out of the six (6) staff members were only able to verify that (R1’s) eating habits had changed. According to (S5) (R1) was not eating and verbalized of little pain. While (S6) claimed that (R1) ate but in small amounts and was being assisted. (S1) stated that (R1) was not in need of any special diet and was on regular diet.

On October 03, 2025, and October 21, 2025, between 9:35 AM and 03:45 PM, the Department interviewed resident members identified Resident #2 through Resident #11 (R2-R11). Ten (10) out of the eleven (11) resident members could not corroborate this allegation. Ten residents confirmed that they receive adequate nutritional dietary needs.

The Department was unable to interview Resident #1 (R1) due to (R1's) passing on July 20, 2025.

The Department reviewed the Physician Report (LIC 602A dated 08/09/24) for Resident #1 (R1), indication of no special dietary needs. The facility's charting notes documented on 07/11/25, (R1) were weak and had a lower intake of food.

Additionally, a review of the Medication Administration Record (dated 07/01/25 to 07/31/25) showed that (R1) was prescribed (11) medications, of which (10) had side effects that could affect appetite (ref: National Institutes of Health). A further review of the Facility Menu has been approved, as indicated by Nutrition Menu Solutions.

(Evaluation Report continues LIC 9099-C)

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with Melissa Serafin, and copies of the reports were provided.