Complaint Investigation Report

Review of both facility records and hospital records reveal the following:

R1 was discharged from a health care facility and admitted to this facility on 08/31/24.

At discharge from the health care facility, there is record that R1 has a pressure injury greater than stage 2.

R1’s physician report indicates a history of skin condition or breakdown with an explanation of a stage 4 pressure injury.

On 11/15/24, R1 was transferred to the hospital for weakness.

Review of hospital records obtained by LPA on 04/12/25 confirm R1 was admitted into hospital on 11/15/24 for weakness and wounds.

Hospital records also reveal that R1 had multiple wounds, notably one Stage 4 and one Stage 3, not identified when resident was admitted to the facility o 08/31/24.

Licensee has no home health records on file to document these wounds were being treated while R1 was in care at the facility.

Investigations Branch (IB) and LPA Cava attempted to obtain R1’s home health records from the home health agency to no avail.

Based on the information obtained, there is sufficient evidence that the facility admitted and retained R1 with a prohibited health condition. Moreover, it appears that licensee failed to meet R1’s needs as R1 developed multiple pressure injuries while in care at the facility. Therefore, based on the information obtained, the allegations of the Licensee admitting R1 with a prohibited health condition and R1 developing multiple pressure injuries in care are Substantiated. Citations issued on the 9099D.

Licensee advised of possible Civil Penalty and Enhanced Civil Penalties (ECPs) may be assessed.