Complaint·October 10, 2025

of wandering, elopement, and stimulation in order to engage and maintain proper quality of life unto R1. In addition, it was learned that R1 had several physical conditions which required staff to check up on R1 with R1's Activities of Daily Living (ADLs), medication management, and proper documentation of any changes to R1's overall status in order to address them and integrate new policies and procedures. Based on a review of the medical records for R1, it was learned that R1 was sent to the local medical facility on several dates requiring extensive treatment and follow up with hospice and wound care. It was learned that in the month of December 2024, R1 was seen at the local medical facility for severe sepsis due to an infected wound that required adequate cleaning and a prescription for antibiotics. Follow up visits were conducted to the local medical facility for R1 in regards to the same issue of sepsis and was even admitted to the local skilled nursing facility as well for treatment and labs. It was learned that several admissions were also made in the month of January 2025 for the same medical issue related to severe sepsis for R1 with the discovery of a Stage IV pressure ulcer as well to the sacrum area. Upon discovery of the Stage IV pressure ulcer, it was initially deemed to be unstageable since the scar tissue was thick and the ulcer was unable to be evaluated at that time for proper assessment. A licensed medical professional was tasked to clean and clear the wound area for R1. It was learned that R1 was then discharged from this local medical facility with a referral for wound care and another one for hospice care. Based on a review of the forms and documents conducted during the course of this investigation, it was learned that proper notifications were not given to the family or responsible parties for R1 in regards to the hospital visits and changes to R1's medical conditions. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated representative at this time. Exit Interview