complaint·October 7, 2025

On 06/10/2025, resident R1 was found with pressure wound on coccyx and bilateral hips. On 6/11/2025, R1 was sent to urgent care. R1 was diagnosed stage 2 or stage 3 pressure wound and was prescribed with cream for 7 days. Home health services was recommended to treat R1's pressure wound. R1 returned to the facility on the same day. A doctor appointment was made with R1's Primary Care Physician on 6/25/2025. On 06/16/2025, home health service agency contacted the facility to schedule a wound care appointment, but R1 was admitted to hospital emergency room due to R1's fainting on the same day. The hospital noted R1's pressure wound was unstageable . On 6/28/2025, R1 was discharged from hospital to a skilled nursing facility. On 07/10/2025, the Department interviewed Administrator (ADM) Rhonald Aranzaso. ADM stated on a yearly basis, the facility staff attend 16 hours of regional center mandatory training including recognition and avoidance of pressure ulcers. ADM stated R1 has been living at the facility since year 2016 and was able to ambulate independently with a walker until March 2024. ADM stated R1 received 1:1 care 6 hours per day since March 2024. ADM stated in June 2025, R1's care was promoted to be a two-person assist. ADM stated on 06/11/2025, the urgent care doctor recommended home health service to treat R1' pressure ulcers. ADM stated from 06/11/2025 to 06/16/2025, the facility staff followed R1's pressure ulcer wound care plan dated October 2024 created by regional center nurse. ADM stated the facility staff kept R1 hydrated by offering water throughout the day and to constantly encourage R1 to reposition. Staff applied barrier creams to the area with redness and applied skin barrier cream to all diapers to wear. ADM stated Home health service agency contacted the facility on 6/16/2025 to schedule appointment for R1, but R1 was admitted to hospital emergency room on 06/16/2025. On 7/17/2025, the Department interviewed 2 staff (S1, S2). Both stated R1 was found with redness on coccyx on 6/10/2025 and was sent to urgent care on 6/11/2025. Both stated they followed R1's pressure ulcer care plan dated in October 2024 to take care of R1's pressure ulcers from 6/11/2025 to 6/16/2025 until R1 was sent to hospital ER due to fainting. S1 stated he/she contacted home health service agency. S2 stated he/she constantly attempted to reposition R1 using wedge pillows and constantly offering R1 with fluids, and applied creams to the ulcer during diaper change. Continue on LIC9099-C. Page 2 of 3. On 08/12/2025, the Department interviewed 2 staff (S3, S4). Both stated they followed R1's pressure ulcers care plan dated in October 2024 to take care of R1's pressure wound. Both stated they constant repositioning R1, changing R1's diaper, keeping hydration of R1. Both stated they received regional center yearly training including pressure ulcers. Based on the interview and record reviewed, the facility staff provided the care based on R1's pressure ulcers care plan for R1's pressure ulcers and arranged the home health service to take care of R1's pressure ulcers. The care the facility staff provided including constant reposition, frequent diaper changes, hydration with liquid, applying skin barrier creams, and changing the dressing. On 6/16/2025, R1 was sent to emergency room due to fainting, so R1's home health service was unable to start. R1's resistant to reposition and threw the wedge pillows away preventing R1 from healing. There is no evidence to show R1's unstageable wound is due to staff neglect. Based on investigation, interviews conducted and records reviewed , the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No citations noted at today’s compliant investigation visit. Exit interview conducted with HM. The report was provided to HM for review. A copy of this report was provided to HM. Page 3 of 3.