The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected. The resident as sent to the hospital on 11/01/2025 and it was determined R1’s toe needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge. Staff also stated that residents are checked on every one to two hours a day to assess their condition.

The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged.

Report Continued on LIC9099-C

The department also reviewed the discharge report from Rose Villa Care Center that advised R1 had a complete traumatic amputation of one right toe. Additionally, the department reviewed Lakewood Regional Medical Center Visit Summary (Dated: 08/16/2025) showing the resident had a prior history of a fall causing a right elbow fracture. Community Care Licensing Division did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated. Title 22, Division 6, Chapter (8) is cited on the attached LIC 9099D. Citation: 87466 Observation of Resident

Deficiencies were issued and plans of corrections were discussed.

Note: *Citations that are not cleared by the POC due date of 1/22/26 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Citation cleared on todays visit.

ECP: At this time, an Enhanced Civil Penalty determination is pending in reference to Health & Safety Code 1569.49(f)“Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

Civil Penalty:

An immediate $500 Civil Penalty was assessed for resident’s toe amputation.

Report Continued on LIC9099-C

The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. They also stated that they believed the resident was going to get medical services for their swollen foot. While S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge on the day they were sent to the hospital for evaluation.

The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated.

The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) that noted R1 was receiving first aid for the swollen foot, but it did not specify that medical services were notified, or any action taken on behalf of the resident. The department also reviewed the discharge report from the Skilled Nursing Facility, Rose Villa Care Center, that advised R1 had a complete traumatic amputation of one right toe.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated. Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Citation 87411 Personnel Requirements – General

Deficiencies were issued and plans of corrections were discussed.

Report Continued on LIC9099-C

An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.