Complaint·April 6, 2026

[CONTINUED FROM LIC9099] Records and interviews revealed that R1 was admitted to the facility on 11/7/2025. Their 10/7/2025 medical assessment and 11/8/2025 appraisal documented diabetes, Alzheimer’s disease, a history of pressure ulcers, which were healed at the time of the assessment. R1 was bedridden and required full assistance with activities of daily living (ADLs). At admission, the administrator (ADM) and one staff (S1) assessed R1. ADM reported that R1’s right great toenail appeared swollen, red, and possibly infected upon admission. S1 stated the toenails were long and the toe worsened over time. Charting shows that 11/11/2025, ADM documented redness on R1’s feet and toenails and notified the Licensee, who planned staff training. No further related documentation was indicated until 12/5/2025, when ADM recorded that R1’s responsible person (OS1) reported a possible foot infection. On 12/10/2025, R1 was hospitalized during a routine doctor appointment due to the progressed infection, which was not addressed by the facility until it was found by outside source (OS1). During interviews, ADM and S1 acknowledged observing the toe worsen and that R1 complained of pain. S1 reported this to R1’s responsible person, who arranged a podiatry appointment with a two month wait. Neither ADM nor SI notified R1’s physician. When asked by the Department, ADM stated no medical care was obtained because R1’s responsible person was already aware and no other skin issues were noted. ADM also confirmed that R1 began developing wounds after attending a day program in late November. Charting corroborated this and documented that on 12/5/2025, R1 returned from day program with a re-opened wound on their upper left back. Three days later, it was noted that R1’s medical provider was contacted to request a wound assessment, guidance for treatment, and any wound care supplies. S1 said that on 12/9/2025, R1 returned from the program with bandages, cream, and instructions for a pressure wound on the shoulder and for the toe. ADM acknowledged that the wound had progressed and reported that they notified R1’s physician, and not their responsible party when it progressed. [CONTINUED ON LIC9099-C] [CONTINUED FROM LIC9099-C] Staff two (S2), responsible for bathing and skin checks, confirmed receiving instructions to apply cream to the pressure injury when repositioning R1 every two hours but denied noticing concerns about the toe. Interviews were conducted with OS1 and R1’s physician (PCP), who became R1’s provider on 12/1/2025. During an intake assessment on 12/8/2025, PCP noticed R1’s infected toe and a stage 2 pressure injury on the upper left shoulder. A follow up on 12/10/2025 showed progression, including blood around the toenail bed, posing significant risk due to R1’s diabetes. Emergency treatment was arranged, and R1 was hospitalized for five days before transferring to a skilled nursing facility for extended treatment. PCP stated they were never notified by the facility of R1’s progressed toe infection. Hospital records reviewed from 12/10/2025–12/15/2025 confirm diagnoses with photos of diabetic ulcers on both great toes, a diabetic foot infection, and pressure injuries to the sacrum and upper left back. R1 required hospitalization for five days and subsequent treatment at a skilled nursing facility following hospital discharge on 12/15/2025. A preponderance of evidence supports that facility staff failed to observe R1’s changes in condition and report as required to R1’s responsible person and physician. The evidence further supports that the facility did not arrange emergency medical care for a serious toe infection which required hospitalization. Both allegations are substantiated and cited on LIC 9099(d). Pursuant to Health and Safety Code §1568.0822 an immediate civil penalty was assessed (see LIC 421 IM). Additional civil penalties remain under review with the Department’s legal division and may be assessed at a later date. An exit interview was conducted, and the report and appeal rights were provided to Administrator Octavio Vazquez, whose signature acknowledges receipt.