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32 | Notes and UCLA internal Medicine & Pediatrics Progress Notes Post-discharge follow-up dated 5/8/2025.
The investigation revealed the following:
Allegation 1: Resident sustained multiple pressure injuries due to lack of care from staff.
On 09/24/2025, LPA conducted phone interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff members stated Resident 1 (R1) was regularly assisted by staff with care for pressure injuries whenever R1 allowed assistance. Staff also reported that on several occasions, R1 refused and discontinued wound care services provided by Intra Care Home Health Providers Inc.
On 01/07/2026, LPA conducted interviews with Residents 1-7 (R1–R7) and 6 out of 7 residents stated that they have never sustained multiple pressure injuries, either in the past or currently, while at the facility due to lack of staff care. These residents also expressed confidence that if they were to develop pressure injuries, staff would provide appropriate care. LPA attempted to interview R1; however, R1 no longer resides at the facility.
Allegation 2: Staff did not ensure that resident's hygiene needs were met.
On 09/24/2025, LPA conducted phone interviews with staff members 1-6 (S1-S6) and 6 out of 6 staff stated staff members ensure all residents’ hygiene needs are met, including those of Resident 1 (R1). LPA also reviewed documentation indicating that R1 refused and terminated care services provided by Intra Care Home Health Providers Inc. Additionally,6 out of 6 staff stated R1 was assisted with hygiene needs whenever R1 allowed staff to help.
On 01/07/2026, LPA attempted to interview R1; however, R1 no longer resides at the facility. Residents R2, R3, R4 and R5 stated that they currently do not require assistance with hygiene needs but expressed confidence that staff would assist them if needed. Residents R6 and R7 stated that staff members assist them with hygiene needs as scheduled and/or as needed.
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