Complaint Investigation Report

including Special Incident Reports with fax confirmations, and documents for Resident 1 (R1) and Resident 2 (R2). On 12/24/2025, at approximately 5:28 pm the Department conducted interviews with Designated Responsible Staff, Aaron Feingold; on 3/10/2026 at 2:24pm conducted interviews with Family 1 (F1); and on 3/13/2026, at 9:46 am conducted interview with former administrator Denise Gilroy. The Department attempted multiple times to interview former Staff 1 (S1), who was the staff directly involved when R1 went to the hospital. However, S1 did not show up to the interview location and did not answer additional attempts to contact them for interview.

R1’s facility file was reviewed, including home health records and Incident reports. Records provided that R1 had diagnoses of Anemia, End Stage Renal Disease, Type 2 Diabetes, and was on Dialysis. R1 did not have any cognitive conditions and is able to communicate. Per R1’s medical assessment and care plan, R1 requires assistance with dressing, grooming, showering, incontinence care, and medication management.

During the investigation, medical records from Valley Presbyterian Hospital and home health records from Savanna Home Care, Inc. were collected and reviewed. R1’s home health records confirmed that the resident was receiving skilled nursing visits every day, prior to being transferred to the hospital. The home health records also confirm that the resident developed a Stage 1 pressure injury on 10/10/2025, and R1 received a referral for wound care the same day. On 10/13/2025, the home health records updated that the wound had progressed to a Stage 2 pressure injury.

On 10/14/2025, R1 was transported to the hospital and arrived around 11:13am. Per the Incident Report, R1 complained of right leg pain and the Administrator called 9-1-1. Records indicate the “Dispatch Complaint” for R1 was a “Diabetic problem” and the chief complaint was altered mental status. Hospital records indicate R1’s sacrococcyx wound was “unstageable” on 10/14/2025 at 11:30pm. R1 was admitted to the hospital due to the altered mental status, bradycardia, and hyperkalemia. Medical records indicate R1 had a history of end-stage-renal disease, was blind, and previously had a stroke'