Complaint Investigation Report

Outside Agency Service Documentation (dated 09/13/2025 & 11/21/2025), Resident Assessment (dated 09/17/2025), OMNI Wound Physicians (date of service 11/21/2025), Outside Agency(Omni Wound Physicians) /Service Documentation (dated 11/21/2025) and UCI Lakewood Medical Records (dated 11/21/2025)

The investigation revealed the following:

Allegation: Resident sustained an unstageable pressure injury due to staff neglect/lack of supervision

It was alleged that the facility failed to provide adequate care and supervision to a resident, resulting in the development of a significant medical condition identified an unstageable sacral wound on a resident who has a history of Alzheimer’s and dementia.

On 12/03/2025 at 10:57am, the Department interview the former administrator (A1) in regards to the allegation. A1 stated he did not know the resident’s skin-check schedule, did not recall any pressure-injury prevention procedures, did not know when the pressure injury was first observed, and was unaware of any documentation or repositioning logs. A1 repeatedly stated information was “unknown to me,” indicating no direct knowledge of the resident’s wound, monitoring, or care practices.

On 12/02/2025 between the hours of 9:27am - 3:10pm, the department conducted 8 staff regarding the allegation.

3 out of 7 staff confirmed the allegation and stated R1's pressure injury was bleeding and required hospital transfer. S1 reported notifying the LVN several times and stated not being trained for wound care. S2 stated the wound was first observed by another caregiver and that hospice did not respond quickly. S2 explained that the facility cleaned around the wound and covered it with gauze before sending the resident to the hospital. S6 stated repeatedly reported the wound and that Home Health never came to assess it. S6 also stated the medtech did not monitor the wound closely and that documentation between medtechs was often missing.

5 out of 7 staff did not confirm nor deny the allegation and mentioned general care routines such as daily body checks and repositioning is documented. None of 5 staff who did not confirm nor deny the allegation had direct knowledge of the R1's pressure injury.