Complaint Investigation Report

Allegation #1: Staff neglect resulting in unstageable pressure injuries.

It is alleged that the staff's neglect of Resident #1 (R1) led to unstageable pressure injuries. Reports indicate that (R1) was hospitalized, and a medical examination revealed multiple wounds. Specifically, there is a 7 cm by 5 cm sacrococcygeal deep pressure tissue injury, an unstageable scapular wound measuring 3 cm by 2 cm with full-thickness tissue loss and necrotic tissue, and a 1 cm by 1 cm unstageable ankle wound with full-thickness tissue loss and eschar. No further information has been provided regarding this matter.

On January 2, 2026, January 23, 2026, and February 27, 2026, between 08:00 AM and 02:30 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff confirmed that Resident #1 (R1) developed pressure injuries while in their care. According to (S1, S4, and S5), (R1) arrived at the facility on March 21, 2025, without any pressure injuries and showed no signs of such injuries, including the one that later developed on the upper mid-back.

Throughout (R1's) residency, staff observations from (S1, S4, and S5) indicated a decline in (R1's) condition. (R1) exhibited a loss of motivation to walk, increasing weakness, and a tendency to remain in bed throughout the day. Despite being repositioned every two hours, (S2 and S3) noted that (R1) still developed pressure injuries while in care. Additionally, (S1 and S5) reported noticing redness on (R1's) back starting in August 2025, which later progressed into a pressure injury. By the time hospice care began on November 5, 2025, the injury had progressed to stage III.

On February 24, 2026, March 2, 2026, and May 5, 2026, between 09:35 AM and 4:10 PM, the Department interviewed witness identified as Witness #1 (W1). (W1) reported that (R1) went into "septic shock" from an "unstageable" pressure wound that developed at the facility, where (R1) was not receiving hospice care. During the last four weeks, care was provided while (R1) was seated in a recliner, worsening the wound.

On February 24, 2026, and May 05, 2026, between 03:25 PM and 04:10 PM, the Department interviewed witness identified as Witness #2 (W2). (W2) stated that (R1) had passed away on December 7, 2025, and advised contacting (W1) for further information on the matter.