NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | 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 |
NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | 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 |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Under Appeal
Type A
10/04/2025
Section Cited
CCR
87468.2(a)(4) | 1
2
3
4
5
6
7 | 87468.2(a)In addition to the rights listed in Section 87468.1...the elderly shall have all of the following personal rights: (4) To care, supervision...to meet their individual needs and are delivered by staff ...qualifications, & competency to meet their needs. This requirement was not met as evidence by: | 1
2
3
4
5
6
7 | ED/S9 stated he/she will conduct in person training, meet with the staff to ensure they are reading & reviewing the rights and care plan of residents. Will have staff review their job description and go over mandated reporting modules for every employee starting 10/8/2025. ED will plan by POC due date of 10/4/25 |
 | 8
9
10
11
12
13
14 | Based on interviews and document reviews on 07/12/25. S1 to S3 & S5 to S7 did not ensure that R1s wound was treated & addressed in a timely manner to prevent the wound from getting infected. S7 admitted that he/she did not implement daily wound care dressing for R1 until 07/17/25. | 8
9
10
11
12
13
14 | (cont.) Which pose/poses an immediate health, safety and personal rights risks to persons in care. |
Under Appeal
Type A
10/04/2025
Section Cited
CCR
87211(a)(1)(D) | 1
2
3
4
5
6
7 | 87211(a) Each licensee shall furnish to the licensing agency such reports..including, but not limited to, the following(1) A written report shall be submitted to the licensing agency and to the person responsible...of the occurrence of any of the events specified in (A) through (D). (D) Any incident which | 1
2
3
4
5
6
7 | ED/S9 stated will ensure that staff is knowledgeable with the reporting requirment based on their reporting procedures to management, licensing and responsible parties. ED will training on incident reports by 10/8/2025. ED will submit written plan of correction by 10/4/2025 |
| 8
9
10
11
12
13
14 | (con't.) threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
Based on interviews and documents review, on 07/10/25 S1 noticed bruising on R1s right shin, S1 reported to S3, however, S3 did not document until 07/12/25 & did not inform | 8
9
10
11
12
13
14 | R1's RP. S1 to S3 & S6 to S7 did not follow procedures for reporting requirements as stated by ED. Which pose/poses an immediate health, safety and personal rights risk to residents in care. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Under Appeal
Type A
10/04/2025
Section Cited
CCR
87705(b)(1)(A) | 1
2
3
4
5
6
7 | 87705 Care of Persons with Dementia(b) Licensees shall be responsible for...(1)Ensuring staff receive ... training ...specified in Section 87208...(A)Dementia care...knowledge about... skincare, communication...This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | ED/S9 will conduct an in-service training on dementia 1 on 1 with staff and ANX home health regarding safety, observations of changes in condition, skincare checks & wound checks & reporting to proper chain of command. Target date for training is 10/14/25. ED will submit written plan of correction by 10/4/25 |
| 8
9
10
11
12
13
14 | Based on interview & record review, on 07/12/2025, S1 to S3, S5 to S7 lacks the comprehension for dementia care, by not addresing R1s wound with proper skincare. There was break in communication by not reporting R1s injuries to R1s RP & to S9 in a timely manner. S6 stated he/she did not | 8
9
10
11
12
13
14 | (cont.) have enough training & guidance from S7 to recognize the wound was getting worse. Which pose/poses an immediate health, safety & personal right risks to persons in care. |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |
1
2
3
4
5
6
7
8
9
10
11
12
13 | This is a continuation of the complaint received on 7/21/2025
5 staff were interviewed S1, S2, S3, S5 and S6 were interviewed, all reported that R1 was combative, bumps into the walls of the facility while wheeling himself/herself while on the wheelchair and scratches himself/herself with long nails. R1 does not allow staff to clip his/her nails. 4 Residents were interviewed (R1, R2, R3 & R4) and stated that staff were caring and gentle, mindful of their needs and have not seen staff abuse a resident. S6 stated that staff are always careful and gentle with R1 and the nail mark does not make sense to him/her or how R1 acquired the injury. During R1s doctor's appointment, it was noted that R1 has cellulitis on the right forearm, right arm flexor and the anterior right leg.
Based on interviews and document reviews Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No defiency issued based on CCR Title 22. A copy of the report was provided to ED Minnie Weber. |
| Unsubstantiated | Estimated Days of Completion: |
|