Complaint Investigation Report

Allegation: Staff did not prevent a resident from developing pressure injuries while in care

During investigation, the Department conducted interviews of facility staff (ADM, S1, S2) & R1’s responsible party (POA), witness (W1) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 06/16/23 and resided at the facility until 01/28/26. R1 was assessed with mild cognitive impairment, non-ambulatory, needs assistance transferring in & out of bed and did not have a history of skin breakdown as shown on R1’s physician’s report dated 06/07/23. On 01/15/26, R1 was admitted into hospice care and diagnosed with a total of 5 pressure injuries on his back (three stage 2 pressure injuries), left buttock (one stage 2 pressure injury) and sacrum (one stage 3 pressure injury) and a tumor wound. On 01/27/26, responsible party (POA) removed R1 from the facility due to unsanitary conditions. W1 visited R1 at POA’s home and observed five pressure injuries on R1. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not prevent a resident from developing pressure injuries while in care was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to prevent resident from developing multiple pressure injuries while in care. Additional civil penalty related to serious bodily injury is pending review.

Allegation: Staff did not administer medication as prescribed

During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff confirmed with LPA that they were giving a topical medication orally to R1 by placing the powder inside water and giving it for him to drink until hospice nurse pointed out this error. Review of R1’s hospice care orders dated 01/20/26 showed topical powder was to be applied to R1’s right ear tumor wound 2X per week. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not administer medications as prescribed was found to be substantiated.