Follow-up on corrections·September 25, 2025

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the Concierge and explained the purpose of the visit. During the Department’s investigation for complaint control # 22-AS-20250218081, the following was discovered: Resident #1 (R1) was admitted to the facility on November 24, 2022, and resided in Memory Care. Per Physician report dated October 31, 2024, R1 had a diagnosis of Hydronephrosis with renal and ureteral calculous obstruction, sepsis and Mild Cognitive Impairment. Physician report further assessed R1 was non-ambulatory and a maximum assist for all self-care needs and activities of daily living. On December 4, 2024, facility progress notes document that, “the resident’s left heel is noted with a small purple/red discoloration non-blanchable. The care team was instructed to reposition resident every two hours, elevate the resident’s legs and support R1’s heels with a pillow for support.” LPA spoke with Health Service Director if facility has a log that tracks how often a resident is turned. The facility currently does have a log to track frequency of turning of residents. On December 5, 2025, facility progress notes by LVN at 8:04pm document, “Pt noted to have unstageable wound on Left heel.” Care staff continue to observe the unstageable pressure injury in the progress notes and applied foam dressing and wound care. On January 16, 2025 Home Health delivered heel protectors to apply in heels daily. (Continued on LIC 809-C) (Continued from LIC 809) Home Health Notes from January 29, 2025, documented a large eschar on the left heel of R1 and an appointment was scheduled with Primary Care Physician at 3:30pm. R1’s Power of Attorney (POA) was notified. Physician addressed pressure ulcer of left heel, unstageable pressure injury and gave a referral order for hospice. Home Health notes confirm this diagnosis and nurse applied Betadine to the area on February 1, 2025. R1 was sent out to the hospital on February 5, 2025, for further evaluation of a urethral rupture and Urinary Tract infection. R1 returned to the facility on February 6, 2025, at 12:30am with antibiotics. On February 10, 2025, R1 is noted with a pressure injury on the right hip, as well as the unstageable wound on left heel. General Manager (GM) and nurse spoke with POA about wound concerns and R1 was transported to Emergency Room for further evaluation. Facility Progress notes dated on February 18, 2025, document that POA spoke with GM and reported R1 was in a Skilled Nursing Facility (SNF) and would be discharged from Aegis Senior Living. Based on Department record review and interviews, it is determined that Resident #1 (R1) was diagnosed with an unstageable pressure injury on R1’s left heel on December 5, 2024. The facility retained the resident with a prohibited health condition until February 10, 2025. The following is being cited per California Code of Regulations, Title 22. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f) An exit interview was conducted with Kurt Knauer, General Manager, and a copy of this report, the LIC 809-D, the LIC 421IM and Appeal Rights were provided to the facility.