Complaint Investigation Report

Staff neglect resulted in a resident sustaining pressure injuries while in care.

It was alleged that Resident 1 (R1) was observed with untreated wounds on their backside. To investigate this allegation LPA conducted an interview with Administrator Designee and S2 and LPA was informed that R1 was admitted to the facility on 05/15/2025 and hospitalized on 05/20/2025. LPA was informed that the Administrator failed to complete a proper assessment of R1’s condition upon admission to ensure appropriate wound care services were in place. Furthermore, LPA was informed that S2 observed R1 with a wound on R1's backside during R1's stay at the facility. On 05/17/2025, S2 received a call from a Home Health nurse notifying the facility of R1’s wound assessment appointment. LPA reviewed Home Health records and it was confirmed that R1 was assessed by Lifespring Home Health on 05/17/2025 for wound care. R1 received the first documented wound treatment on 05/20/202. Lastly, On 05/30/2025, LPA reviewed hospital medical records, which documented that R1 was evaluated with a Stage II pressure injury on the left gluteal area.

Based on interviews and record reviews, the facility failed to conduct a proper assessment of R1’s wound condition upon admission and failed to ensure consistent wound care services were provided. Therefore, the allegation is Substantiated .

Staff are not able to properly position a resident while in care.

It was alleged that R1 remained in a wheelchair for four (4) days and staff were unable to reposition R1. To investigate this allegation LPA conducted an interview with the Administrator Designee and S2 and both confirmed that staff were unable to move R1 due to R1’s weight (300 lbs.). Furthermore, LPA was informed that the staff only moved R1 for incontinent/diaper changing purposes. Lastly, LPA requested staff training documentation, but the facility was unable to provide evidence of proper training to meet R1’s care needs. Based on interviews and record review, the allegation is Substantiated .

Staff do not have the appropriate equipment to move a resident.

It was alleged R1 was not moved for four (4) days due to lack of personnel and equipment. To investigate this allegation LPA conducted interviews with the Administrator Designee and S2, and both confirmed that the staff were unable to move R1 because the facility did not have a Hoyer lift during R1’s stay from 05/15/2025 to 05/20/2025. Furthermore, R1 was not properly assessed prior to admission, and the Administrator failed to order the necessary equipment in advance. As a result, on 05/20/2025, R1 attempted to stand, fell, and remained on the floor until paramedics arrived. Continue on LIC 9099C