Complaint·August 20, 2025

(Continuation from LIC9099) R1 moved into the facility on October 31, 2023, and was non-ambulatory and spent extended periods either in bed or in a wheelchair. R1 also experienced bowel and bladder incontinence, residual numbness in their lower back and buttocks, and limited mobility. These conditions placed R1 at high risk for skin breakdown. However, the facility file contained no Appraisal/Needs and Services Plan and no other documented plan for monitoring or managing R1’s elevated risk. In March 2024, a Med-Tech (MT1) observed what appeared to be an early-stage pressure injury on R1’s tailbone, describing it as a “black mark.” MT1 indicated that she texted a photo of the pressure injury to Wellness Director Petricia Ward. According to MT1, no treatment or physician follow-up occurred after she elevated R1’s condition. MT1 further reports that R1’s care was not sufficient and left Savant of Riverside due to the ongoing neglect she witnessed. Around the same time, a caregiver (C1) observed a small mark on R1’s tailbone during an adult brief change, which she described as a ‘dot’ or ‘blackhead pimple”. C1 claimed she told one of the Med-Techs but could not recall who. On a subsequent day, the mark appeared larger, prompting her to ask a Med-Tech to re-check it. Another caregiver (C2) recalled the pressure injury starting as a small cut, then worsening and developing a foul smell. C2 reported her observations to Ward and the Med-Techs. C2 noticed that the overnight shift caregivers were not very diligent in changing R1’s briefs through the night as C2 often found R1 soaked upon her arrival at 6:00 AM. C2 added that she reported her observations but does not feel management was as responsive as they should have been. Despite these early reports, no charting or wound care orders appear in the facility’s records until April 7, 2024. Facility LVN (LVN) stated she remembered that one of the caregivers reported R1 had a pressure injury sometime in April. LVN added that she told Ward the wait for R1’s physician to order home health was too long, as the wound had developed odor and suspected infection. (Continue to LIC9099C) (Continuation from LIC9099C) LVN emphasized that Ward did not share her urgency to send R1 to the hospital. LVN shared that she left Savant of Riverside because she had concerns about the overall level of care provided to the residents, which included having insufficient staff to provide care. A Med-Tech (MT2) remembered that R1 was “not well taken care of”. MT2 confirmed being in the room with MT1, who was upset about R1’s wound. MT2 told MT1 to show Ward pictures of the wound. She recalled Ward saying she would handle it, but no follow-up action was observed. On April 15, 2024, a Med-Tech (MT3), learned that R1 had a fever and worsening wound pain. MT3 stated she contacted non-emergency transport to take R1 to the hospital. When R1 initially refused, EMS was called and transported R1 to the hospital ER. MT3 said Ward later admonished her for sending R1 out, indicating that home health was scheduled for the following week. On April 16, 2024, at the hospital ER, R1 was found to have an unstageable, infected pressure ulcer with necrotic eschar at the L-1 to L-3 level. Neurosurgery determined it was unrelated to R1’s prior back incision. On April 17, R1 underwent surgical debridement and a temporary colostomy to manage bowel incontinence, and a wound vacuum was placed. R1 was discharged to the facility on April 24 with orders for home health wound vac and colostomy care. From April 25 to May 13, 2024, a home health agency visited three times per week for wound vac and colostomy care. On May 15, a hospice agency assumed wound care. Hospice records from May 15th show an unstageable medial sacrum wound measuring 11.4 x 6.4 x 2.5 cm with 50% eschar, tunneling, and moderate slough, along with signs of infection including yellow drainage and odor. Hospice documentation notes that facility staff had been asked to increase peri-care frequency, but R1 continued to be found in a “heavily saturated pull-up at each recent visit”. The hospice nurses recorded that the wound was in decline despite antibiotics and recommended urgent consideration of IV antibiotics and surgical debridement to prevent osteomyelitis. (Continue to LIC9099C) (Continuation from LIC9099C) On May 29, R1 was admitted to the local hospital, began IV antibiotics, and underwent two surgeries over a two-day period. R1 was discharged to the facility on June 3rd but returned to the hospital the same day for further IV antibiotic treatment. R1 was later admitted to a skilled nursing facility on June 10th and moved out of the facility July 2nd with the wound unresolved. During the interview, Ward stated she was verbally informed about the wound but denied ever receiving a text message or photo of it from any Med-Tech. She was certain that April 7th was the first date she became aware of the wound and denied having knowledge of it prior to that date. Ward acknowledged, however, that the wound she observed on April 7th had developed before that day, describing it as a ‘black sore.’ She indicated that she immediately requested home health at that time. Ward explained that any reddened area or abrasion should be reported right away, which she said did not occur. She placed blame on the direct caregivers and Med-Techs for failing to report the initial skin breakdown. Ward further agreed that R1 should have been sent to the hospital earlier than April 15th, and that R1 should not have returned to the facility after discharge. She stated that she raised this concern with upper management, emphasizing that nursing staff in upper management make the final decision about whether a resident like R1 can return. Ward clarified that even as Wellness Director, she did not have the authority to decide when a resident should be sent to the hospital. When interviewed, R1 stated that the facility “let it go,” which led to the infection. R1 reported developing a fever of 103 degrees with hot and cold sweats, at which point the facility sent him to the hospital ER for treatment. R1 believes that more prompt action by the facility could have prevented the wound altogether, and that earlier medical intervention might have kept it from progressing to the point of requiring two surgeries. Records reflect that on April 7, 2024, Wellness Director Ward documented for the first time that R1 had a coccyx wound, contacted the resident’s physician, and requested home health. On April 10, a Physician Assistant (PA) examined the resident, charted a sacrococcyx ulcer of approximately one week’s duration, and ordered a STAT wound care referral. Facility records show no evidence of skilled medical care being provided to R1 between April 7th and April 15th. (Continue to LIC9099C) (Continuation from LIC9099C) Ward acknowledged the wound likely existed before April 7th, and agreed the delay in hospitalization should have been shorter. Multiple staff reported systemic issues at the facility, including lack of documentation, inadequate staffing, residents left soiled overnight, and pressure from management to avoid calling 9-1-1. Witness statements were consistent in describing delays in wound care and lack of response to concerns. Medical and hospice records confirmed the wound worsened, resulting in severe infection and multiple surgeries. Based on observations, interviews, and review of records, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. The California Code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. The licensee was advised that a civil penalty is being considered pursuant to Health and Safety Code Section 1569.49(f). An exit interview was conducted and a copy of this report along with Licensee Appeal Rights (LIC 9058 03/22) were provided to Wellness Coordinator, Brianna Jones