Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff are not properly caring for resident’s open wound

It is being alleged that upon admittance to Martin Luther King Jr. Community Hospital on 10/15/25, C1 had a wound and a blister on his left leg. On 4/20/26, the department reviewed records and found the following: Date admitted to the facility, per Admissions Agreement, 12/23/24. Diagnosis on admissions per Physician’s Report dated 11/22/24, diabetes, chronic kidney disease, and activities of daily living (ADL’s). Per review of Preplacement Appraisal dated, 12/23/24, overall health condition included diabetic neuropathy, non-ambulatory due to blindness, could dress on his own, needed assistance with bathing, medication, and cash. Per interview with S1 on 10/20/25, staff only does body checks upon admission and it was not known that C1 had a wound on his leg. S1 stated that C1 does not inform staff when he takes a shower. Per interview with S1, C1 only request towels when he’s done with his showers. Per review of Resident’s Shower Slips dated, 10/3/25 and 10/10/25, C1 requested towels after his showers. Per review of Needs and Services Plan dated, 12/23/24, C1 was able to move on his own and do ADLs with minimal assistance and encouraged to take showers. Per Report of Behavior Observed by Staff, dated 8/26/25, stated C1 went into facility’s office to inform staff that he went to the doctors and he submitted paperwork to staff which stated C1 was diagnosed with cellulitis of the leg, with no follow up appointments nor medication given. Per incident report dated 10/15/25, C1’s caseworker visited this facility to notify staff that C1 was admitted to the hospital following an evaluation. Per C1’s request, the caseworker stated the admission was for high blood pressure to conceal the actual reason from staff. On 10/15/25 following a medical evaluation, MLK Hospital diagnosed C1 with a diabetic skin ulcer. Per review of Report of Behavior Observed by Staff on 10/18/25, a facility resident mentioned to staff that he would see C1 scratch at the back of his leg with his shoe. Per interview with S1 on 4/20/26, C1 transferred to another facility on 11/4/25. On 4/20/26 and 4/23/26, the department attempted to interview C1, but he refused LPA Shirleys telephone call.

LPA interviewed staff 1 – staff 5 (S-1 – S-5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed Client 2 – Client 6 (C2 – C6). Of those who interviewed 5 out of 5 denied the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not properly caring for resident’s open wound,” therefore, the allegation is unsubstantiated.