Complaint Investigation Report

Regarding the allegation that Staff neglect resulted in resident sustaining multiple pressure injuries. It was alleged that Resident #1 (R1) had multiple unstageable pressure injuries when admitted to the hospital on 01/08/26. LPA’s record review revealed that R1 was admitted to the facility on 10/20/25 and was admitted with Hospice services on the same day. Upon admission at the facility, R1 had an existing stage 1 pressure injury under the care of Hospice wound care. Further review also revealed that R1’s pressure wound is worsening on 12/27/25. Hospice Wound visits for R1 were conducted every day immediately thereafter to care for R1 wounds until R1 was hospitalized on 01/08/26. LPA’s interview with R1’s family member confirmed that R1’s wounds were being taken care of by the nurses and facility staff.

Based on the information gathered during the course of the investigation, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.