Complaint Investigation Report

On 11/06/2025 the Department conducted interview with Administrator (A1), and on 11/19/25 The Department conducted interview with witness #5 (W5). On 09/22/2025, a review was conducted of MEND Wound Care wound care records. On 09/29/2026, the Department conducted a review of Home Health Records from Hollywood Home Health.

The investigation revealed the following:

Allegation: Staff retained a resident with a stage 4 pressure injury.

It was alleged that the resident in care developed a Stage 4 sacral pressure injury, multiple pressure injuries, skin tears, and a possible fungal infection while residing at the facility.

On September 29, 2025, the Department interviewed Residents R1, R2, R3, and R4 regarding the allegation. Three (3) out of the four (4) residents denied having pressure injuries and reported no concerns related to skin breakdown. One (1) resident reported having a bedsore but was unable to recall whether treatment was being provided.

On September 16, 2025, and September 29, 2025, the Department interviewed W1. W1 reported that the resident did not have any pressure injuries upon admission to the facility but had numerous chronic medical conditions and was receiving services from Hollywood Home Health. W1 stated there was never an indication that the facility was neglecting the resident; however, W1 expressed dissatisfaction with the wound care provider's treatment of the resident's wounds. W1 further reported that the facility did not inform them that the resident could no longer remain at the facility if the wound progressed to a prohibited condition.

On October 2, 2025, the Department interviewed W2. W2 stated that after reviewing home health nursing notes, W1 became aware that home health personnel had concerns regarding the wound care being provided. W2 further reported that the resident would likely have benefited from a higher level of care and believed the wound observed was consistent with a Stage 4 pressure injury despite being treated primarily with topical medication.

On October 8, 2025, the Department interviewed W3. W3 reported that the resident had previously been hospitalized in January 2025 and, at that time, a Stage 3 sacrococcygeal pressure injury had been identified. W3 stated that appropriate treatment and preventative measures following the hospitalization may have prevented further deterioration of the wound.