complaint·June 3, 2025

R1's Responsible Party informed the department that they did not know of the wound until it was discovered by R1's doctor during a visit on April 23, 2024. R1's responsible party was not informed by the facility of R1's wound prior, despite two of four staff members being aware of the wound. During file review it was revealed that the resident’s physician report dated August 17, 2023 stated that the resident does not have the capacity to bathe, dress or groom themselves and is bedridden. The LIC 603A Appraisal dated August 04, 2020 completed by facility staff documents that R1 requires assistance with dressing. An after visit medical summary dated April 23, 2024, was reviewed that stated the resident had a stage 2 pressure ulcer of the right foot. Following the doctor’s visit a home health agency came to the facility to provide wound care to the resident. Based on observation, interviews, and information gathered during the investigation and review of all documents obtained. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Rose Martellotti and a copy of this report, LIC 9099-D, LIC811 and appeal rights were left at the facility.