complaint·March 12, 2026

Continued from LIC9099... Further interview with W1 indicated that R1 “finally stated they had pain in toe. It takes a lot for a dementia person to realize something is wrong” and when staff checked the toe there was an open and weeping ulcer. Upon assessment at the hospital it was found the ulcer had turned necrotic which had reached the bone and required a partial amputation. Review of Resident Notes indicated that toe sore was initially observed on 12/02/2025 and R1 was taken to the hospital by their Responsible Party on 12/05/2025 where R1 was admitted and subsequently had their toe partially amputated. Review of five (5) Resident Shower Sheets for R1 indicated two (2) shower/body check refusals and three (3) successful showers and body checks. Three (3) of three (3) successful body checks indicated that R1 was visually assessed for lesions/blisters/abnormal skin and did not require their toenails to be cut. Review of photographs submitted indicated R1’s toenails had grown past the edge of their toe and were curling down. Further review of photographs indicated that R1’s toe had substantial amounts of slough, was weeping fluid, and had turned a yellow/black color. Based upon evidence gathered, there is a preponderance of evidence to prove that the allegation has been SUBSTANTIATED and is valid. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. See LIC9099D. Exit interview conducted with Health and Wellness Director, whose signature on form confirms receipt.