Complaint·May 4, 2026

Caregivers notified the Wellness Director (WD) and Wellness Coordinator (WC). On 11/09/25 redness was noticed on both of R1’s heels at the pressure points. Staff were instructed to put a pillow under R1’s heel to offload the pressure. Although R1’s skin condition was observed by appropriate personnel, no proper skin assessment was provided, and R1’s skin condition was not discussed with their doctor or other skilled professionals. On 11/10/25 and 11/13/25, staff notified R1’s family of the redness on their heels. Multiple staff noticed R1 screaming since 11/07/25. Between 11/07/25 and 11/18/25 conditions of R1’s pressure injuries got worse. On 11/18/25, R1 was sent to the hospital to seek medical attention. A review of facility records revealed the following information: Caregiver notes from 11/07/25 identified redness on R1’s left heel. R1 expressed some pain. By 11/09/25, redness was noticed on both of R1’s heels. On 11/10/25 and 11/13/25, the condition of the pressure injuries worsened. Staff continued to monitor R1’s condition by putting pillows under their heels to keep their legs elevated, though R1’s care plan was not updated with this procedure. Further review of facility records revealed although facility staff had knowledge that R1’s pressure injuries were getting worse, no initial and continued wound assessment were completed. The doctor was not notified to properly assess the wound and assign skilled medical professionals to provide required medical care. Overall investigation revealed that on 11/07/26, while in the facility, R1 developed pressure injuries. Between 11/07/25 and 11/18/25, the condition of the pressure injuries got worse, and facility did not take appropriate steps to ensure R1 is receiving required medical care and other services. On 11/18/26 R1 was sent to the hospital with unstageable wound on their left heel. Therefore, based on interviews and record reviews the allegation is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today for a violation resulting and immediate health and safety risk to R1’s health and safety. The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided. Regarding the allegation “Staff changed residents healthcare provider without consent of resident or residents responsible party” it was alleged facility staff switched the insurance of Resident #1 (R1) without consent. Interviews with Staff #6 (S6) at 2:05 p.m. on 11/20/25 and Staff #4 (S4) at 2:15 p.m. on 11/20/25 revealed they had no knowledge of R1’s insurance coverage or changes. Interview with the administrator at 11:45 a.m. today revealed R1 never returned to the facility after their hospitalization on 11/18/25. The administrator also had no knowledge about R1’s insurance coverage or change. Interview with Witness #1 (W1) at approximately 2:00 p.m. on 02/13/26 revealed a dispute in the rental agreement affected R1’s insurance. Staff #7 (S7) requested W1 to switch R1’s insurance in order to qualify for a government program. Interview with S7 at 12:15 p.m. today confirmed they requested R1 to switch insurance, but it never happened. W1 also confirmed R1’s insurance was never changed. No records reviewed indicated R1’s insurance was switched. Based on interviews and record review, staff did not change R1’s healthcare provider. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns observed during today’s visit. Exit interview conducted. Copy of report provided.