Inspector’s narrative
What the inspector wrote
On 12/08/2025, 12/10/2025, and 12/11/2025, the LPA conducted phone interviews with W3. On 12/17/2025, the LPA attempted to contact the Resident's DPOA telephonically again but received no response. During the investigation, hospital records and Home Health records were requested and reviewed.
On the allegation "Resident developed pressure injuries that worsened due to neglect "; it is the concern of the Reporting Party (RP) that on 11/06/2024, Resident 1 (R1) was admitted to St. John’s Regional Medical Center, for treatment of severe pressure wounds. It was reported that on 10/16/2024, R1 was moved from a skilled nursing facility to Reese Joy Care Home. RP also states there are discrepancies in R1’s care as staff at Reese Joy Care Home reported that R1 did not have any wounds when they were placed in their care but stated R1 began receiving home health services on 10/19/2024.
A review of the resident records revealed that R1 was initially admitted to the skilled nursing facility (SNF) on 08/18/2024 through 10/16/2024. A review of 10/16/2024 Summary and Post-discharge Plan of Care- V4 did not indicate any presence of pressure injuries. The discharge plan had a dedicated page to input any pressure injury information which was left blank. Additionally, R1 was discharged with an order to receive physical therapy, occupational therapy and speech therapy only as outpatient therapy services from Ease and Comfort Health. On 10/16/2024, R1 was discharged and admitted to Reesejoy Care Home.
A review of R1’s admitting Preplacement Appraisal (LIC603) dated 10/16/2024, Appraisal/Needs and Services Plan (LIC625) dated 10/16/2024, and Physician’s Report (LIC 602A) dated and signed 10/14/2024 did not indicate any pressure wounds. R1’s LIC602A also indicated that there wasn’t any history of skin condition or breakdown.
However, medical records reviewed indicated that on 11/06/2024, R1 was admitted to St. John’s Regional Medical Center for altered mental status/tremors. The Nursing Progress notes dated 11/07/2024, notated that R1 had sacrum/buttocks 12 x 6 x UTS cm 100% yellow/brown slough, peri wound erythema, small serous discharge, unable to stage pressure injury present on admission, left heel: 2 X 3 cm purple nonblanchable, dry, deep tissue injury present on admission, and left elbow: 1.5 X 1.5 cm, red, dry chronic pressure injury, present on admission. Wound care notes revealed that photos and measurements were taken on 11/7/2024, of R1’s wounds on their buttocks, left ankle, left heel, left forearm and left heel at the hospital. Report will continue on LIC9099-C, 3rd page.
The Administrator stated that R1 had redness upon admission on the buttocks, on the hands and feet, and staff were the ones treating R1. The Administrator recalls paperwork that R1 was receiving wound care but did not recall seeing any nurses go into the facility and stated they were basing the information provided to the LPA from the paperwork and conversations they had with R1’s DPOA. The Administrator also revealed that they believed R1 had stage 1 pressure injuries although no medical professional evaluated R1. When asked if they ever ordered any home health wound care for R1, the Administrator stated no and that R1’s DPOA handled all R1’s medical care. The Administrator also indicated that R1’s DPOA provided the name of R1’s physician but with no contact information. The Administrator attempted to contact the physician by using Google to obtain the phone number and advise them of the pressure injuries but was unsuccessful in locating the physician and informed R1’s DPOA. The Administrator continue to state that on November 6, 2024, R1 was admitted to St. John’s Hospital. A review of R1’s LIC 602 indicates it was signed by a physician from the skilled nursing facility the resident previously resided at which is a different name the DPOA provided as R1’s physician.
Interview with a representative (W1) from At Ease and Comfort Home Health whose contact information was listed on the skilled nursing’s discharge paperwork, revealed that R1 never received any home health care from the agency. However, interviews with a representative (W3) from Ease and Comfort Home Health with a different contact number which was listed on the medical records revealed that R1 only received one visit from them, at most two, was not able to provide information if there was any care rendered on those visits, and that it was difficult to scheduled visits to see R1 as their “caretaker” wanted to be present but scheduling a date was difficult. However, the representative stated that there was no wound care ordered for R1 and no wound care was ever provided to R1 by them during those visits. The representative was unable to state if the referenced “caretaker” in the home health records was a facility staff or R1’s DPOA and advised the LPA they were basing their information on the nursing visit notes which provides no name and only list contact as caregiver. R1 was sent to the hospital on November 6, 2024, and services with the agency stopped.
Record review revealed the facility had no home health records for R1 which will be addressed under a separate report. A review of R1’s home health records obtained from Ease & Comfort Home Health revealed that R1 was seen by a home health nurse on 10/19/2024 and 10/29/2024.
Report will continue on LIC9099-C, 4th page.
The records indicated that R1 was assessed on 10/19/2024 for their start of care, and the assessment indicated that R1 had no pressure ulcers/injuries or no stageable pressure ulcer/injuries. Additionally, the records revealed that on 10/29/2024, a home health nurse conducted a skin assessment and indicated “there were signs of breakdown on coccyx area, pcg advised to turn patient every 2 hours, and use pillows to protect bony prominences to prevent from further deterioration, MD office notified, and continued monitoring was advised due to limited mobility and incontinence.” Wound care worksheet completed by the home health nurse on 10/29/2024, noted that R1 had a stage 1 pressure ulcer on their coccyx area that measured 4cmx 5cm (closed), a stage 1 pressure ulcer on their right hip and left hip (both closed), and a superficial skin tear on their left arm (scab). Furthermore, home health communication notes revealed that on 10/22/2024, and 10/26/2024, SN reported designated caregiver refused home health visits at this time due to limited availability, the caregiver will only approve nurse visits when their schedule permits, home health visits cannot be conducted in the absence of the caregiver, caregiver was informed by SN about the benefits and risks of home health visits and the risk associated with missed visits. On 10/29/2024, the physician’s office was notified via telephone and fax that R1 presents with a pressure ulcer and requires wound care evaluation, no treatment orders have been issued at this time. On 10/30/2024 and 10/31/2024, the physician’s office was contacted for the 2nd and 3rd time via telephone, and a message was left regarding wound care evaluation, and the caregiver was called and advised to contact the doctor because the home health was not able to get a hold of any staff. No treatment orders had been issued at that time, and caregivers were advised to seek emergency room for wound care treatment. On 11/1/2024, the home health agency attempted to contact R1’s caregiver to verify whether the patient has been transported to the hospital as the PCP had not been in communication with the agency. No return call had been received from caregiver at that time. On 11/2/2024, the SN reported that they were unable to reach “pcg” to schedule an appointment. On 11/06/2024, SN reported that upon calling to schedule appointment for R1 they were informed that R1 had been admitted to the hospital. Home health services placed on hold until further notice. On 11/15/2024, the home health agency reported that per following up with R1’s family, R1 was at the hospital, and they were making decision on patient’s care. R1 was discharge from home health services. Records did not indicate who the caregiver or family member they were in communication with was. The LPA attempted to contact R1’s DPOA on three different occasions, however was unable to interview the DPOA to clarify if they were the “caregiver” reference in the home health records as the Administrator alleged the DPOA was the person who was in contact with home health agency.
Report will continue on LIC9099-C, 5th page.
Based on the information gathered there is sufficient evidence to support that the allegation occurred. On 10/16/2024, R1 did not have any pressure injuries documented in the skilled nursing facility’s discharge paperwork or Reesejoy Care Home admissions paperwork. A review of home health records revealed the resident was assessed on 10/29/2024 with the presence of stage 1 pressure ulcers on their coccyx area that measured 4cmx 5cm (closed), a stage 1 pressure ulcer on their right hip and left hip (both closed), and a superficial skin tear on their left arm (scab). On 10/31/2024 HH records indicate they advised the caregiver that they were unable to get hold of the physician to obtain wound care orders and to take R1 to the emergency room. Although R1 was not taken to the hospital until 11/06/2024 for altered mental status/tremors. At the hospital R1 was diagnosed with unstageable pressure injury in their sacrum/buttocks, deep tissue injury present on their left heel and dry chronic pressure injury on their left elbow. The information gathered supports the allegation of Resident developed pressure injuries that worsened due to neglect as R1 was not receiving wound care and was not hospitalized until 11/06/2024. Therefore, the allegation “Resident developed pressure injuries that worsened due to neglect” is deemed
Substantiated
at this time.
Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). An immediate $500 civil penalty was also issued today. Administrator Roberto Dela Vega Ramirez was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, copy of this report and Appeal Rights were issued.
