Complaint Investigation Report

Interview with W1 indicated that R1’s pressure injuries developed from prolonged supine immobility prior to hospital admission. Incident report dated 04/23/2025 revealed that the facility reported R1 had two wounds when R1 returned from hospital on 04/20/2025. Interviews with S1, S2 and Home Health indicate consistent statements of staff being attentive to the residents’ care needs and staff did not neglect to provide care. Interview with Home Health and Home Health notes revealed staff were trained by home health to provide care R1 and that R1 was receiving home health care from 3/28/2025 to 05/16/2025.

Staff did not ensure that resident in care was turned as needed.

Interviews with staff, Home Health and record review revealed that R1 was repositioned every 2 hours. R1's home health notes indicated that R1 was receiving ongoing monitoring and education to help prevent exacerbation of conditions and reduce the risk of hospitalization.

Resident developed a pressure injury while in care due to staff neglect.

Interviews with staff, Home Health and records review revealed that R1 did not develop pressure injury while in care and staff did not neglect to provide care. R1 was receiving home health services from 03/28/2025-05/16/2025.