Complaint Investigation Report

During the investigation, LPA toured the facility and observed no conditions indicating excessively hot or cold indoor temperatures. At the time of the visit, the indoor temperature throughout the facility ranged between 68 and 78 F degrees, which is within a safe and comfortable range. Residents interviewed stated the home was comfortable and did not report concerns regarding room temperature. LPA did not observe or obtain documentation showing the facility failed to maintain a safe and comfortable indoor temperature.

It was alleged that the facility does not provide food of good quality. LPA interviewed the Licensee, Administrator, staff, and residents and toured the kitchen and food storage areas regarding the allegation. The Administrator stated residents receive three nutritious meals each day with snacks available between meals. Staff stated meals are prepared daily and modified when needed to meet physician-ordered dietary requirements.

During the facility tour, LPA observed an adequate supply of fresh produce, meat, dairy products, and pantry items. Food was properly stored, and the kitchen and food preparation areas were clean and sanitary. Residents interviewed stated they enjoyed the meals served and did not express concerns regarding the quality or quantity of food provided.

It was alleged that the facility neglected to report a pressure injury. LPA reviewed Hospital records, which showed R1 was admitted on January 13, 2025. During the hospitalization, hospital staff identified a pressure injury to R1's right heel. The hospital records documented the pressure ulcer as present upon admission and later described the wound as unstageable. The hospital records included documentation that the wound was present upon admission and referenced information reported by R1's family member regarding a prior ulcer. However, the hospital records did not determine when the pressure injury developed, identify its cause, conclude that Queen's Home 2 caused the injury. The records further did not document that the facility had been notified of the pressure injury before or during R1's hospitalization. The discharge records included orders for continued skilled nursing and wound care after R1 left the hospital.

LPA reviewed Home Health (HH) records for R1, which showed HH provided skilled nursing services before R1's hospitalization and a second HH agency provided services after hospitalization. The records did not document a pressure injury before R1 was hospitalized and showed HH’s services transferred to another home health agency after being hospitalized.

(Complaint Investigation Report continued on LIC9099C)