Complaint Investigation Report

Allegation: Facility staff neglect resulting in residents developing pressure injuries while in care.

It is alleged that residents in Memory Care have Stage 3 and 4 decubitus ulcers. It is alleged that residents were left in their bed because they have behaviors.

Based on records reviewed, R6’s Hospice flow chart from October 4, 2023, indicated a wound care professional came to the facility to follow up on their wound. R6’s hospice flow sheet from October 4, 2023, to July 23, 2025, does not state that the wound has gotten worse. The report states that either treatment was done or treatment was refused because R6 was aggressive. R6’s facility’s progress notes from November 13, 2024, to February 5, 2025, stated R6 was receiving wound care from their hospice company. There are no notes that indicate the wound was a result of staff neglect nor did the staff note that the condition got worse. R9 was admitted to the facility on August 31, 2019, according to their face sheet dated March 5, 2022. R9 returned to the facility from a skilled nursing facility on January 24, 2025, according to the facility progress notes dated January 24, 2025. Progress notes dated January 26, 2025, staff discovered a right heel wound and coccyx stage 2 wound. R9’s hospice care plan start date for the pressure 2 wound on coccyx was on January 31, 2025. There are no indications on record from the facility progress notes, hospice care plans, and other documents that the facility staff neglect led to pressure injuries for the residents in care.

Based on interviews conducted, eight out of eight residents and eight out of eight staff denied allegation that the facility’s staff neglect resulted in residents developing pressure injuries while in care. All staff and residents stated that they have not heard a resident develop pressures due to staff neglect.

Based on observations, LPA Kim did not see any form of neglect at the times of visit on February 6,2025, and August 15, 2025.

Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and all staff did not corroborate that the pressure injuries occurred to residents due to staff neglect. LPA was able to verify that staff did not neglect residents leading to pressure injuries based on reviewing resident hospice care plans, facility progress notes, and other document records.