Complaint Investigation Report

Allegation: Resident sustained pressure injuries due to staff neglect

It is alleged that R1 sustained pressure injuries due to staff neglect. During R1's interview, R1 reported noticing sores on their back approximately one week prior to the interview after experiencing itching and scratching the affected areas. R1 stated that staff later bandaged the wounds and that a physician from SCAN Embrace prescribed a topical cream to be applied twice daily. R1 reported that the cream had not consistently been applied as ordered. During resident interviews, Residents R2 through R5 reported having no concerns regarding the care and supervision provided by facility staff. The residents stated that staff are responsive to their requests for assistance and regularly check on residents with higher care needs. The residents acknowledged that staff response times may occasionally be delayed due to staff being busy; however, they reported that staff ultimately provide the requested assistance. During staff interviews, staff consistently reported that R1 requires extensive assistance with mobility, incontinence care, and other activities of daily living. Staff stated that R1 is repositioned every two hours to prevent skin breakdown; however, some staff reported that R1 frequently declined repositioning despite encouragement and education regarding the importance of changing positions. Staff indicated that the facility became aware of the reported sores approximately one week prior to the interviews. Staff further reported that R1's bed had recently been changed from a regular bed to a hospital bed to improve repositioning efforts and facilitate the provision of care. Additionally, staff reported that medical consultation was obtained and treatment measures were implemented. Several staff members expressed the belief that the affected areas were irritation associated with scratching rather than pressure sores. During witness interviews, W1, a physician familiar with R1 who last evaluated R1 on 06/08/2026, reported that the facility promptly notified the medical team regarding skin redness and possible pressure sores on 06/01/2026. W1 stated that a nurse practitioner assessed R1 and determined that the areas represented erythema rather than pressure injuries. W1 further reported having no concerns of neglect related to skin care or pressure injury prevention.

Allegation: Staff are not meeting residents bathing needs

It is alleged that staff are not meeting R1's bathing needs. During R1's interview, R1 reported that they are scheduled to receive bathing assistance on Tuesdays and Saturdays. However, R1 stated that for approximately four to five weeks, they did not receive one of their scheduled Tuesday baths. R1 denied refusing bathing assistance and reported that staff informed her that a caregiver had forgotten to provide the bath. R1 further stated that staff did not begin cleaning their back until they reported concerns regarding sores. During resident interviews, Residents R2 through R5 reported having no concerns regarding the facility meeting their bathing and personal hygiene needs. The residents stated that they are routinely offered bathing assistance and denied going extended periods without being offered hygiene services. Although the residents noted that staff responses may occasionally be delayed due to staff being busy, they reported that staff ultimately provide the requested care. ( co ntinued on 9099C)