complaint·May 21, 2025

Staff would contact R1’s Responsible Party (RP) often, who would then come to the facility to try and calm R1 to get them to comply with staff. At one point during an outburst of anger, R1 punched a staff member in the abdomen. During their interview, AD stated that is when R1 developed some redness on their buttocks area. AD stated R1’s RP was notified about the change in demeanor and the redness, and R1’s RP informed AD they would talk with R1’s doctor. Per Green Meadows Home Health Care Medical Records dated November 3, 2021, Home Health did an initial interview and check of R1 and found no skin injuries or problems on November 3, 2021. On November 22, 2021, the Home Health nurse noticed redness around the Coccyx region and instructed facility staff to rotate R1 more often in order to avoid a skin ulcer. On December 6, 2021, Home Health came to the facility again to check R1’s wound. R1 became combative and would not allow Home Health nurse to inspect their Coccyx area. On December 9, 2021, R1’s RP contacted R1’s doctor who instructed R1 be transported via 911 to the hospital. Upon arrival at the hospital R1’s injury of an unstageable ulcer was discovered. During their interview, R1’s RP stated they were very involved with the care R1 was receiving while at the facility. R1’s RP stated they would be informed of R1’s verbal and physical outburst, and their resistance in allowing staff to provide care. Per R1’s RP, they asked R1 not be transported to the Veterans Affairs (VA) hospital or by emergency ambulance if avoidable. R1’s RP stated they did not want R1 to go to the VA hospital for care for personal reasons and did not want R1 to be transported by ambulance to limit expenses that are associated with emergency care. Per R1’s RP, both they and the facility could have made better decisions for R1’s care. R1’s RP stated staff at the facility did their best to assist R1 and to comply with their requests but subsequently caused delay in care that would have helped prevent R1 from developing an unstageable pressure injury. During their interview, AD stated they attempted to have R1 transported to the hospital when their mental status changed, and R1 showed redness to his Coccyx area, however, R1’s RP convinced AD to delay in transporting R1 for personal and financial reasons. Per AD, although they felt otherwise, they conceded with RP’s requests. (Cont. LIC9099-C) Based upon staff interviews, and record review of associated medical records there is evidence to corroborate the allegation that R1 developed an unstageable pressure injury due to Neglect/Lack of care and supervision. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (see LIC9099-D) and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health & Safety Code 1569.49(f). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.