complaint·May 29, 2025

According to the first allegation, on July 30, 2022, R1 was observed to have a Stage 4 (four) pressure ulcer on the left buttocks while being treated for an unrelated urinary catheter issue. Based on staff statements, on July 30, 2022, Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) were walking the facility patio when S1 observed a catheter bag on the ground. S1 and S2 believed the bag belonged to R1 and proceeded to R1’s room, where it was found that R1 was missing such catheter bag. R1 explained to staff that the catheter had been leaking but was unaware the bag was missing. Staff proceeded to contact outside source agency that provided catheter care and was instructed to contact emergency personnel for assistance. According to S1, prior to emergency personnel arriving, S1 and S2 cleaned/wiped R1’s groin area and whole body, while not observing any irregularities with skin. Medical records collected revealed once R1 arrived at hospital, it was found that R1 had a Stage 4 (four) gangrenous pressure ulcer to left buttocks. According to interview with Administrator, no staff was aware that R1 had developed a pressure injury. Interview with multiple staff revealed that R1 was known to be refusing care since May of 2022 and care records corroborated such information. Interview with Administrator confirmed that Administrator was aware of R1 refusing care and did not take action to prevent such issues. It was also alleged that R1 was not assisted with incontinence care for bowel movements. Interviews with multiple staff revealed that R1 was refusing bowel incontinence care from staff. Records collected revealed that as of May 25, 2022, R1 had a change in condition, and required assistance with activities of daily living (ADSL), was bed bound, and forgetful. Documentation shows that these changes were also documented on June 8, 2022, and July 15, 2022, with additional information that R1 was defecating in bed, wheelchair, and shower. Interview with S1 revealed that R1 was denying staff from entering room and often hiding feces throughout the shared cottage. Administrator could not provide documentation that such changes and behaviors were reported to R1’s Physician and/or family. Based on staff and outside source interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation that staff neglect of R1 resulted in a Stage 4 (four) pressure injury and staff did not meet R1’s incontinence care needs. The allegations are therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). The Department has determined this violation resulted in injuries to the resident in care.  An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM.  Currently, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director Jonathan Wheeler, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-Cx2, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Executive Director Jonathan Wheeler, signature on this form confirms receipt of documents. According to the first allegation, on July 30, 2022, R1 was believed to have a leaking and malfunctioning urinary catheter for two days and facility staff did not seek medical attention for R1. According to records collected, R1 was receiving urinary catheter care from an outside source agency. Interviews with staff revealed that on July 30, 2022, Staff 1(S1), Staff 2 (S2) and Staff 3 (S3) were walking the facility patio when S1 observed a catheter bag on the ground. S1 and S2 believed the bag belonged to R1 and proceeded to R1’s room, where it was found that R1 was missing such catheter bag, R1 explained to staff that catheter had been leaking but was unaware the bag was missing. Staff proceeded to contact outside source agency that provides catheter care and was instructed to contact emergency personnel for assistance. R1 was taken by emergency personnel on the same date of incident. Records collected revealed that R1 had a visit by outside source agency medical professional and had a urinary catheter change on July 29, 2022. It was also alleged that as of July 30, 2022, facility licensee knowingly retained a resident with a prohibited condition Stage 4 (four) pressure ulcer without an exception from the Department. Interview with S1 and S2 established that care staff were unaware of R1’s pressure injury. Interview with Administrator revealed R1 has refused care since May 2022, and had not allowed staff to provide care or make observations of resident’s physical conditions. Records collected did not confirm R1 was diagnosed with pressure injury until July 30, 2022.  Interview with outside source medical professional revealed that a pressure injury on R1 had not been observed during regular care or reported by R1. Based on interviews, and record reviews the preponderance of evidence standard has not been met, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided .