complaint·March 20, 2025

According to S1 and other staff members who were interviewed during the investigation explained that Resident 1 (R1) deals with on and off again rash like irritation to the groin area. Document review revealed that R1 is on hospice and the rash like irritation was being treated with Calomoseptine cream since January 15, 2025. The cream did not appear to be treating the rash and it was reported to the hospice nurse, and on March 14, 2025 Hospice provided an order for a new medication (Nyastatin powder) to treat R1’s rash like irritation on the groin area. During the investigation the department received several photos of different residents that dealing with skin discolorations, rashes, and skin tears. During a phot0 review of R1’s groin area, LPA observed what appeared to be redness on all sides of the groin area with darker red spotting all around the private area. The irritated area appears to be bleeding or was bleeding as blood can be seen on the residents legs and inside the pull up. LPA Haley also received photos of Resident 2 (R2) with red spots on the tail bone area and on a private area on R2. In the photo of R2’s private area the skin appears to be broken. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.