Complaint Investigation Report

The investigation consisted of the following: An initial complaint visit was completed by LPA David España on 02/16/2024. A subsequent visit was completed by LPA Perry Scott on 3/7/2025. On 02/16/2024 LPA requested copies of the following: Resident's medical records, including diagnosis and treatment of pressure sores. Documentation of care provided by appropriately skilled professionals. Records of staff training on pressure sore prevention and care. Resident's care plan and daily care logs. Incident reports. Staff disciplinary records. Resident's medical records documenting any injuries. Facility policies on abuse prevention and reporting. Resident's personal property inventory. Facility policies on safeguarding residents' belongings. Staff training records on resident rights and property protection. Any reports of missing items.

Meal plans and menus. Food service logs. Dietary requirements for residents. Staff training records on food service and nutrition. Copies of rent increase notices. Facility policies on rent increases and notifications. Resident's admission agreement. Communication logs with residents or their representatives. Facility policies on resident rights and staff conduct. Maintenance logs for resident mobility devices. Inspection records for wheelchairs and other mobility devices. Resident's care plan addressing mobility needs. Staff training records on equipment maintenance and safety. LPA España interviewed Resident 1- Resident 3 (R1-R3) and Staff 1 - Staff 4 (S1-S4).

Investigation revealed the following: Allegation #1: Resident sustained bed sores due to staff neglect.

On 02/16/2024, LPA España interviewed Resident 1 - Resident 3 (R1-R3) regarding the allegation. Of those interviewed, 1 of 3 residents stated they had no bed sores, the other two did not answer the question. On 02/16/2024, LPA España interviewed Staff 1-Staff 4 (S1-S4). 3 out of 4 staff disagreed with the allegation of neglect leading to bed sores. On 2/16/2024 LPA Espana reviewed records for four facility residents and found no indication of any residents being treated for bedsores.