complaint·April 18, 2025

Interviews show staff reported assisting R1 during varies stages of R1 wound treatment. Staff confirmed there were steps in place to reposition R1. However, R1 had a medical condition that caused stiffness, so repositioning was difficult. Staff S2 and S5 indicated they were trained to provide wound care to R1 on the days no skilled nurses were scheduled. The procedure required staff to clean, pat dry, and dress the wound. However, staff never dressed the wound which caused the wound to worsen. Staff only applied ointment, repositioned R1, and attempted to keep R1 dry. There was no documentation of dressing being applied to the wound. In addition, the facility staff did not maintain a chart or log for R1’s plan of care or change of condition as it worsened. The facility only implemented charting changes after R1 condition changed after 12/2022. Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. An immediate civil penalty is assessed for $500.00, per Health and Safety Code. An additional civil penalty may be imposed per Health and Safety Code 1569.49 (f).