Complaint·October 3, 2025

Staff were interviewed on 08/07/25 and 08/08/25. Staff 1 (S1) stated that on 07/10/25, while attending to R1s needs, S1 and another staff (S2), noticed a purple bruise on R1s right leg shin and notified the medication technician (MedTech) (S3) on-duty. On 07/12/25, while getting R1 ready for the morning, S2 noticed nail marks on R1 left and right arms and hands. S1 stated the nail marks were not there on 07/11/25. S2 then stated to S1 that R1s injury on the right shin “looks really bad.” S1 stated that he/she does not know if S3 or other MedTech reported the injuries to R1s responsible party (RP). S1 also stated that he/she does not know if R1 was taken to his/her physician to be checked. S1 stated that he/she does not know how the injury was missed, because S1 reported the injury right away. Staff 2 (S2) stated that he/she does not document anything during his/her shift. S2 stated that he/she reports verbally any skin issues to MedTech on-duty. On 07/12/25, S2 stated that staff 4 (S4) came to assist and cleaned R1s left and right arm injuries. S2 proceeded to remove R1s pant and sock and discovered that R1s injury on the right shin has worsened. S2 stated the injury was very red, oozing water like gangrene and approximately the size of an apple watch face (42mm). S2 stated “the flesh was growing.” S1 and S2 put a bandage on the injury. S2 did not know if S3 documented the injuries when it was reported. Staff 3 (S3) stated that on 07/12/25, he/she notified his/her supervisor (S7) via text message of R1s arm and shin injury and noted the injuries on the whiteboard but S3 did not report electronically. S3 informed the PM MedTech of R1s injuries to the arms and shin. On 07/18/25, S3 observed the arm injuries were healing, but the right leg shin injury was inflamed and had a pungent discharge. Staff 5 (S5) stated on 07/15/25, nothing was reported regarding R1s injuries and he/she was not aware that R1 has injuries. On 07/17/25, another staff (S8) notified S5 of R1s injuries. S5 stated he/she was very busy and could not attend to R1s injury right away. S5 stated that he/she reported R1s injury to R1s responsible party (RP) when RP came to visit R1 on 07/17/25. S5 stated that on 07/12/25, S3 reported to R1s physician about the injury, but did not document and did not notify RP. S5 stated that the facility has a skin check log and staff are supposed to complete the log and MedTech are supposed to assess skin issues. Page 2 of 3 Staff 6 (S6) stated, on 07/12/25, S6 was notified by S3, that R1 has shin injury and injuries on the arms. S6 cleaned and bandaged R1s arms and observed that R1s shin injury was pink, oval spot that was half the size of a post-it-note. S6 stated he/she did not treat the shin injury because it looked like it's healing. On 07/13/25, S6 reported the injuries to the next MedTech on duty (S10). S6 did not document R1s injuries. On 07/16/25, S6 observed that R1s injuries on the arms were healing but the shin injury turned yellow and was glossy but did not have a foul odor. S6 cleaned and bandage of the shin injury and reported the findings to S3. S6 stated S3 informed S7. On 07/18/25, S5 notified S6 that R1s shin injury was getting worse. S6 stated he/she did not know what to do with R1s injury. S6 feels that he/she did not have enough experience & training to recognize the wound was getting worse. S6 stated that he/she skipped resident health checks due to number of reports that needs to be completed. Staff 9 (S9) stated on 07/12/25 a staff documented R1s arm and shin injuries, however, S9 was not informed until 07/17/25. S9 described R1s right leg shin injury as red, wet and the size of post-it-note, with a faint smell. On 07/17/25, S9 saw skin tears on R1s arms and reported to R1s RP. On 07/17/25 S9 stated that S7, admitted that he/she was aware of R1s injury since 07/12/25 and S7 admitted that he/she did not implement a daily wound dressing change until 07/17/25. S9 stated the facility's protocol for injuries is that MedTech are to follow the chain of command for reporting. S9 stated that S3 reports to S7 who oversees the memory care. S7 did not follow the reporting procedure and did not report to S9. S9 stated that S3 did not properly endorsed injuries to S6 and S3 did not notify and follow up with R1s RP. Based on record review, on 07/12/25, S3 notified S7 and R1s physician regarding the injuries on the left and right forearm. On 07/17/25, S5 notified R1s physician that R1 have a discharge from a wound on the right leg. Based on interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED based California Code of Regulations (CCR) Title 22 87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, 87211(a)(1)(D) Reporting Requirements & 87705(b)(1)(A) Care of Persons with Dementia. See LIC 9099D. Deficiencies were cited during today's visit. An exit interview was conducted with Executive Director, Minnie Lacson-Weber. A copy of the report and appeals rights were provided. page 3 of 3 -- end of report