Complaint Investigation Report

LPA interviewed five (5) out of five (5) residents, staff designee and three (3) staff from 1:14 PM until 2:12 PM. LPA reviewed resident’s records from 2:14 PM until 3:45 PM. LPA took a tour of the physical plant with the assistance of the administrator at 1:13PM. On 3/9/2026, LPA requested R1’s hospital medical records.

Regarding allegation: Resident developed multiple pressure injuries in care due to staff neglect.

It is alleged that on 2/17/2026 R1 had an appointment with their Geriatrician and R1 has several stage 3 wounds. R1 was admitted to the facility on 5/23/2025, record review, appraisal needs and service plan and preplacement appraisal (LIC 603), revealed that R1 did have an unstageable wound on their coccyx. All of the residents interviewed during the investigation did not address any concerns regarding their care at the facility. Hospital medical records reviewed reveal R1 had developed pressure injuries on their coccyx, sacral, and bilateral heel. Wound started developing on 4/14/2025 before R1 was admitted to the facility. An interview with staff revealed repositioning assistance was provided to avoid and give relief to pressure injuries by staff. Interview with R1’s responsible party revealed that they are happy with the care given by the facility and were not aware that R1 required higher level of care or were clear regarding the care hospice will provide.

Records reviewed reveal that all of the staff are trained by the administrator and were following home health instructions on how to care for R1’s wounds. A review of hospital medical records revealed R1 was admitted to home health on 5/29/2025. On 5/29/2025 sacral wound stage 3 was noted to measure 1.5 cm x 1 cm x 0.2 cm. On 8.7.2025 medical records noted coccyx wound was noted as stage 2. On 5/21/2026, LPA called and spoke to R1 family revealed that they refused to admit R1 to hospice. On 11/3/2025, additional wounds were noted to the right heel (full thickness skin loss) stage 3 measuring 2.25 cm x 2.5 cm x 0.2 cm. Family eventually agreed for R1 was to be admitted to hospice on 11/3/2025. On 2/5/2026, it was noted that R1 had stage 3 wounds on their right (R) heel measuring 2.25 cm x 2.5 cm x 0.2 cm. On 2/18/2026 right heel was noted as unstageable.