331880511-2-10-2025-18-AS-JDHS-DE2UZ4-20250219150057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880511
Report Date: 02/10/2025
Date Signed: 02/10/2025 10:57:01 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20211220091157

FACILITY NAME:	PALMS AT LA QUINTA, THE		FACILITY NUMBER:	331880511
ADMINISTRATOR:	PATRICK MCADOO-MORTON		FACILITY TYPE:	740
ADDRESS:	45160 SEELY DRIVE		TELEPHONE:	(760) 345-5353
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	120	CENSUS: 86	DATE:	02/10/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Executive Director, Roland Gandy		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained pressure injuries while in care due to neglect

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/10/2025, Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to deliver complaint investigation findings. LPA met with Executive Director, Roland Gandy and explained the purpose of the visit.
It was alleged Resident 1 (R1) sustained pressure injuries while in care due to neglect. The investigation consisted of facility record review, medical record review, and staff and resident interviews.

Resident 1 (R1) moved into the facility in 2017. The facility’s Physician Report dated 06/14/2021 did not indicate R1 had wounds. The Temporary Service Plan (TSP) that was written on 07/14/2021 mentioned R1 had pressure sores on R1’s buttocks. According to the TSP, home health requested for R1 to be out of bed for meals, to be turned every 2 hours, and completely off R1’s buttocks to promote skin integrity and comfort. According to facility records, R1 received services from home health for Stage II wounds from 06/25/2021 until 08/19/2021. R1 was last seen by home health on 08/19/2021 and then discharged R1 from receiving services.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 18-AS-20211220091157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PALMS AT LA QUINTA, THE	FACILITY NUMBER: 331880511
	VISIT DATE: 02/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A review of home health services records was conducted. An assessment document dated 08/23/2021 revealed the reason for the assessment was for discharge from agency. The certification period was from 06/25/2021 to 08/23/2021 and the date the assessment was completed was on 08/19/2021. Under the Integumentary status heading, the question on whether R1 had at least one unhealed pressure ulcer at State II or higher or designated as unstageable was entered as no. The assessment allows the user to enter the number of unhealed pressure ulcers at each stage and nothing was entered. Further, the number of current Stage I pressure ulcers was listed as zero. A note reads “Patient has no pressure ulcers or no stageable pressure ulcers.” The discharge date is listed as 08/19/2021.

R1 was interviewed where it was revealed R1 was unable to reposition in bed. R1 had a call button where they could call for staff assistance. Interview revealed R1 would be repositioned in bed one time in the morning and sometimes when staff would come to change R1. It was further revealed caregivers would clean R1’s sores put medication on them. The interview revealed R1 was not repositioned frequently. The facility was not able to provide documentation to show how frequently R1 was repositioned by staff.

Hospital records were reviewed. The Patient Education & Visit Summary revealed R1 was seen on 08/27/2021 for bleeding from the coccyx. Discharge notes read follow up with Primary Care Provider (PCP) is needed. Staff interview revealed that a review of hospital discharge paperwork is usually done along with contact with PCP for wound assessment. According to information revealed in the interview, it did not look like the review and contact with PCP was done.

A staff interview revealed a new care plan is developed when pressure injuries are documented. Based on interviews, the facility did not obtain an updated Physician’s Report nor did they update R1’s care plan. Facility Charting Notes revealed seven (7) notes relevant to this investigation. On 08/27/2021, it noted R1 had just returned from the hospital with a dressing in place on the buttocks. On 09/01/2021, it noted the wound on the buttocks did not have a dressing when changing R1. Brief had blood on it. Staff changed and repositioned R1 and left pendent within reach. Staff would continue to monitor. On 09/15/2021 at 1:53am, it was noted that staff responded to a pendant call and found R1 sitting on the floor.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20211220091157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PALMS AT LA QUINTA, THE	FACILITY NUMBER: 331880511
	VISIT DATE: 02/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff noted R1 had been feeling pain on her buttock due to bedsore and had tried to roll on their side but ended up rolling off the bed. On the same day of, 09/15/2021 at 5:38PM, there is another note where staff note the bruising again and indicated R1 had been given pain medication. It was further noted, R1’s buttocks area cleaned and dry, barrier cream applied, bandage replaced and resident was repositioned frequently during the shift. On the charting note dated 10/27/2021, it reads “resident has open bleeding bed sores”. There are no additional notes until 11/26/2021. The charting note dated 11/26/2021, indicates the dressing for R1’s buttocks was not changed during the caregiver’s shift and R1 did not remember if it was done during the AM shift. The caregiver noted R1 was already in bed and would not allow the caregiver to change it. The caregiver further noted they would notify the AM nurse to change the dressing in the AM. On the charting note dated 12/18/2021, R1 was sent to the hospital around 7am due to excessive bleeding from the coccyx wound. It was further noted on the same day, R1 was admitted to the hospital and wound care was being provided to stop the bleeding and tunneling of the wound.

According to a staff interview, staff reported they faxed R1’s Primary Care Physician (PCP) on 12/14/2021 to request R1 receive Home Health Services regarding “Stage II” pressure injuries to the right and left buttocks. According to staff during the, the PCP informed the facility that R1 would need to be seen in-person first. The in-person appointment never took place because records show that R1 was sent to the hospital on 12/18/2021. A review of the Physician Fax and Visit document dated 12/14/2021 corroborated this information. The response from physician was dated 12/15/2021 and indicated R1 needed to be seen for an office visit first.

A review of hospital records was reviewed. They revealed that R1 was admitted to the hospital on 12/18/2021. The diagnosis was decubitus ulcer of buttock. The Photographic Wound Documentation Form dated 12/18/2021, in the emergency department, revealed the wounds were present on admission on the buttocks, bilateral. It was identified as pressure injuries with a diagnosis of decubitus ulcer. The Photographic Wound Documentation Form dated 12/19/2021 indicated, the pressure injuries, present on admission, were staged at Stage III on the right and Stage II on the left.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20211220091157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PALMS AT LA QUINTA, THE	FACILITY NUMBER: 331880511
	VISIT DATE: 02/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

History and Physical/Admission Notes dated 12/18/2021 read Chief Complaint is R1 was brought in by facility with complaint of coccyx pain that is bleeding. R1 denied trauma and states it happened while in the bathroom. The section titled History of Present Illness read R1 presents with buttock decubitus ulcers that have been bleeding, ER staff concerned that R1 may not be getting optimal care at R1’s current facility. Emergency/Urgent Care record dated 12/18/2021 indicated the Medical Decision Making section noted they were unable to arrange for safe discharge with home health given concerns for neglect. Wound Care notes dated 12/19/2021 revealed right buttock stage III was sized at 2x2.5x.1 cm and left buttock stage II was sized at 4x2x.1 cm.

Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on records review and interviews, there was no information found to show that any attempts were made by facility staff to arrange for medical care and follow up with the PCP, as recommended in the discharge notes from 08/27/2021 until 12/14/2021.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D and appeal rights. In addition, an immediate civil penalty of $500 is being assessed. The LIC 421 was also reviewed, provided along with appeal rights. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20211220091157

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PALMS AT LA QUINTA, THE	FACILITY NUMBER: 331880511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/17/2025 Section Cited HSC 1569.49(e)	1 2 3 4 5 6 7	1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies. (e) For a violation that the department determines resulted in the death of a resident, the civil penalty shall be fifteen thousand dollars ($15,000).	1 2 3 4 5 6 7	The Administrator stated staff will be trained on the following the procedures on how to follow each resident's care plan. This is to include training on how to follow up and arrange for medical care and follow ups with PCP. This training requirement is due to the LPA by email on COB on the POC due date.
	8 9 10 11 12 13 14	This requirement was not being met as evidenced by: staff neglect, staff caused serious injuries to resident while in care. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5