Complaint Investigation Report

Staff neglect resulted in resident developing multiple pressure injuries.

It is alleged that the facility staff neglected Resident #1 (R1) which resulted in developing multiple pressure wound injuries in the buttocks area with emitting pus and was not receiving home health or hospice services. To investigate this allegation LPA conducted an interview with the Administrator who denied ever retaining a resident with a prohibited health condition. The Administrator also informed LPA that R1 is receiving home health services since his/her admission to the facility and the treatment for the redness on the buttock area since 04/24/2025. However, on 05/12/2025 a small opening was observed by the facility staff on R1’s buttocks area which was immediately reported to R1’s Primary Care Physician (PCP). Subsequently, R1’s PCP advised the Administrator to take R1 to the hospital emergency room (ER) for further evaluation. On 05/13/2025, R1 was transported to ER and R1 was discharged the same day from the hospital. On 05/16/2025, LPA requested and reviewed R1’s hospital medical records and did not observe any medical information to conclude R1’s pressure wound injuries stage. The medical records indicated that R1 has a small ulceration with no necrosis or eschar. Lastly, interviews with R1 and seven (7) other residents revealed that they are happy with the care being provided by the facility staff and never felt neglected. No sufficient evidence was obtained, thus based on interviews and record review this allegation is deemed Unsubstantiated at this time.

Exit Interview Conducted. A copy of this report provided.