Complaint Investigation Report

Plan (Printed On: 11/24/2025), Lakewood Regional Medical Center Visit Summary (Dated: 08/16/2025, 11/01/2025), Preplacement Appraisal Information (Dated: 08/11/2025), Rose Villa Care Center Discharge Report (Dated: 12/16/2025), Rose Villa order Summary report (Dated: 12/15/2025) and Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) from the facility.

The investigation revealed the following : Allegation #1-Staff did not address residents’ change of condition.

The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected. The resident as sent to the hospital on 11/01/2025 and it was determined R1’s toe needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge. Staff also stated that residents are checked on every one to two hours a day to assess their condition.

The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged.