Complaint Investigation Report

On the allegation "Staff not following residents care plan" the following was found: On 7/16/2025 LPAs A Gomez and T Syess-Gibson conducted the initial investigation visit. During the visit LPAs met with staff 1 (S1), Licensee, resident 3 (R3), and resident 4 (R4). LPAs reviewed available records for R1, R2, R3, and R4. LPAs observed in R3's records that they required assistance rotating every 2 hours. LPAs were at the facility continuously from 1:00PM- 4:15PM and observed that R3 was not rotated until LPAs requested that staff rotate them. On 8/20/2025 LPAs A Gomez and Y Brown returned to the facility to continue the investigation. LPAs observed that the Facility was crushing medications for R3 and R4 without a crush order on file. On 11/4/2025 LPA A Gomez interviewed R1, R2, and witness 1 (W1) . During the interviews with W1 it was disclosed that R1 sustained pressure injuries due to facility staff not encouraging and assisting R1 as discussed as part of their care plan. It was also disclosed that R1 was having flare-ups with their skin due to inconsistent use of their ointment. LPA cross verified this information with text messages from R1's Home Health Nurse. Therefore the allegation " Staff not following residents care plan" is Substantiated.

On the allegation "Resident sustained pressure injuries due to staff neglect" the following was found: On 11/4/2025 LPA A Gomez interviewed W1 and reviewed photos, and text messages from R1's Home health Nurse. R1 was admitted to the facility on 2/1/2025. LPA observed that on 2/7/2025 R1 did not have any pressure injuries on their bottom. On 2/11/2025 LPA observed that a pressure injury had began to form on R1's bottom but was not yet open. According to the Home Health Nurse the pressure injury was developing because of sitting for prolonged periods of time. Nurse advised for R1 to stand and walk every hour to prevent the wound from developing further. Between 2/12/2025 and 2/19/2025 it was documented that the pressure injury on the bottom had opened and developed further. Wound healed by 5/20/2025. Therefore the allegation "Resident sustained pressure injuries due to staff neglect" is Substantiated.