Complaint Investigation Report

R1 also was marked as able to communicate and was marked as non-ambulatory. LPA reviewed daily charting notes for R1 from September 2025 to December 2025 that did not indicate if the resident was turned. Notes reviewed did not indicate staff repositioning R1 or attending to R1s pressure injuries. LPA observed text messages between facility staff and R1s POA regarding R1s pressure injury with updates starting on December 18, 2025, with the last picture update sent on December 23, 2025.

Interviews with staff revealed that 3 of 4 staff were aware of the pressure injuries R1 had obtained. 2 of 4 staff informed LPA that they were treating the pressure injures and communicating with R1s family and providing updates. 1 of 4 staff informed LPA that they inform the medtech on duty when they find something on a resident and the medtech informs the family. 1 of 4 staff were not present at the facility when the pressure wounds were found on R1. 3 of 4 staff informed LPA that they do not recall a time when R1 did not have access to their pull chord.

LPA interviewed 6 residents in care including R1. 3 of 6 residents interviewed did not confirm or deny the allegations. 2 of 6 residents informed LPA that staff help them whenever they call for assistance. 2 of 6 residents informed LPA that the staff answer the pull chord system whenever they have pulled it, even if it was on accident. 1 of 6 residents stated that staff did not always respond to the pull chord system or assist them in a timely manner. 1 of 6 residents informed LPA that the pull chord often fell where they could not reach it making it to where they could not call staff for assistance.

LPA reviewed current staff training on topics such as Resident Care, Skin Care and Elder Abuse. 1 of 4 staff have an active administrators certificate expiring on January 12, 2027.

LPA toured the facility and observed the pull chord system to be operational with all pull chords within reach of residents beds.

Based on information gathered, interviews and tour of the physical plant, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED and no citation was issued.

An exit interview was conducted and a copy of this report was left at the facility.