Complaint Investigation Report

A record review revealed that R1 was admitted to the facility on 03/15/25. On 04/11/25 R1 was brought to the hospital clinic and was diagnosed with a Stage 2 or 3 pressure wound and was eventually referred to and was admitted for home health services for wound care. On 04/29/25, due to wound improvement, the Home Health services terminated. On 06/04/25 however, care staff from the facility called the hospital due to R1’s decline and wound at the sacral region . C are staff was advised to call 911 but called R1’s family member and R1 was brought to the Hospital’s Emergency Room where R1 was diagnosed with Stage IV pressure wound. On 06/14/25, R1 was discharged to a Skilled Nursing Facility (SNF) for pressure wound , further treatment , and recovery.

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

Citation issued, appeal rights explained and given.

Exit interview conducted. Copy of this report issued.