Complaint Investigation Report

Progress Notes (dated 04/22/2025-05/12/2025, Ideal Home Health Records (dated 05/06/2025), California Wound Healing Medical Group (dated 05/01/2025), Outside Agency Documentation (dated 02/09/2024-07/23/2024), Special Incident Reports (dated 05/08/2025), and Emails (dated 08/27/2024, 11/06/2024, 04/03/2025, and 05/04/2025).

On 05/14/2025, at 11:30 A.M., Health and Wellness Director Tamera Gant and LPA Bunker toured the facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit.

On 05/14/2025, between 9:30 a.m. and 12:30 p.m., and on 05/28/2025, between 9:30 a.m. and 3:30 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#3 (S1–S3). On 05/14/2025, at 12:30 p.m., LPA Bunker conducted interviews with resident #1 (R1) and witness #1-#2 (W1-W2).

The investigation revealed the following.

Allegation: Staff neglect resulted in the resident developing a pressure injury.

It was alleged that staff neglect resulted in the resident developing a pressure injury. Staff members #1–3 (S1–S3) interviewed stated that R1 never disclosed a pressure injury. 3 out of 3 staff members stated they did not know about any pressure injury to R1's body. The facility was not required to bathe R1; however, the facility assisted, and R1 was bathed by his home health agency. On 08/27/2024, R1 was ambulatory until R1 sustained a fall while on a visit with his family at church.

R1 required rehabilitation, which R1 received outside the facility. On 09/27/2024, Records indicate R1 developed a pressure injury while at the rehabilitation center. Studio Royale sent a representative to the rehabilitation center for evaluation before R1 returned to Studio Royale. The rehabilitation center made note that R1 was able to return to Studio Royale; however, upon R1's return to Studio Royale, it was noted that the pressure injury had not been resolved. The facility made several attempts to provide many options for R1 and communicated these options to his power of attorney (POA) with no results. Upon a scheduled doctor’s appointment, R1 was subsequently admitted to the hospital for the pressure injury. The facility staff were interviewed and denied any neglect or lack of supervision. The Department found no evidence that R1's pressure injury manifested while at the facility.