complaint·March 28, 2025

R1’s after summary visit indicated that R1 wound was at a stage two but it was manageable. According to S1 observation R1 wound was on the merge of develop to a stage three, but it was manageable with preventative care. W3 advise the care staff to make sure to rotate the resident every two hours, and make sure to have some time for the resident to be air out. W3 came three time within a week, and the wound got worse. The staff keep on telling the family that the resident was doing better and getting better, but as a wound nurse the condition was getting worse. The family finally agree to send R1 to the hospital. During the interview process when care staff was asked why they didn’t call 911 if R1 condition was getting worsen. Care staff indicated that R1 family member didn’t agree for us to call 911 emergency, but contact the non-emergency. W2 and W3 observed that R1 was not being clean and observed R1 wound got worsen even though care staff claimed that had follow the advised that was given. W3 observed that R1 was being neglected and was left in solid diaper, and had reminded them many times and gave them multiples instruction, and as well as paper instruction. W2 observed that all the paper instruction was gone. From my experience as an RN if a resident was being taken care of as instructed the wound would not get worse and develop to a stage four. W1 stated “Yes, I believed that the facility takes go care of my mom, but in term of rotating my mom they were not doing as much as they were supposed to do. At the end we can see that my mom condition got worse. The facility never suggested that my mom would got worsen, until I was notified by the ACI nurse”. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D. Exit interview conducted with Administrator Lorica Hipolito a copy of this report and appeal right was provided.