Incident investigation·July 7, 2025

Licensing Program Analyst (LPA) conducted an unannounced case management visit and met with Administrator (ADM) Rhonald Aranzaso. On 7/3/2025, the Department received a report regarding resident R1's incident. On 7/7/2025, LPA interviewed Administrator (ADM) Rhonald Aranzaso. ADM stated resident R1 moved in the facility on 4/1/2016. ADM stated based on the R1's pre assessment dated 2/29/2016, R1 was ambulatory, able to reposition self, and without any pressure injury. ADM stated R1 was unable to walk by self in 2023 and was with cognitive impairment in 2023, but R1 still was able to reposition self and without pressure injury. ADM stated on 10/30/2024, R1 had stage 1 wound. ADM stated the facility consult with the facility RN consultant and developed care plan for R1's wound. ADM stated R1's wound was healed on 11/28/2024. ADM stated on 6/11/2025, the facility staff found R1 had wound and brought R1 to urgent care. ADM stated the urgent care prescribed ointment and Silicon Foam dressing for R1 and to consult home health agencies to take care of R1's wound. ADM stated he/she contacted 2 home health care agencies. ADM stated the facility staff take care of R1's wound based on R1's wound care plan. ADM stated on 6/16/2025, R1 was passed out in the restroom with 2 staff. 911 was called and R1 was sent to hospital emergency room. On 6/19/2025, R1 was transferred from hospital ICU to regular room. Continue on LIC809-C. Page 1 of 2. ADM stated on 6/27/2025, the facility had a care conference with hospital and SARC, and decision was made to discharge R1 to skilled nursing facility for rehabilitation and wound care. ADM stated on 7/7/2025, R1 is still at the skilled nursing facility. LPA interviewed 3 staff. 3 out of 3 staff stated they saw R1 had redness on the hip before 6/11/2025 the date R1 was sent to urgent care. 3 out of 3 staff stated the applied cream to R1's redness area based on the facility care plan. LPA requested R1's pre assessment form, physician report, appraisal needs and service plan, daily activity log, and incident reports. LPA observed 3 staff and 1 residents in the facility. This case needs further investigation. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.