Complaint Investigation Report

On 09/02/25, LPA Chang interviewed Witness 1 (W1). W1 reported that on 08/29/25, Resident 1 (R1) and R1’s responsible party (RP) met with R1’s wound care physician for treatment of a Stage 1 pressure injury. W1 stated that based on his/her observations, W1 believes R1 experienced neglect or lack of supervision by the facility. W1 stated that the facility applied a Band-Aid to R1’s wound and did not provide timely or appropriate wound care. W1 further indicated that facility staff were responsible for R1 sustaining the pressure injury on his/her heel. W1 further states that RP told W1 that around 07/28/25, RP saw bruises on R1s arms and a skin tear, there was no report or documentation of the injury. RP continued to state to W1 that RP inquired about the injury with the former Memory Care Director (MCD) who stated that he/she will investigate the bruises but did not give an update to RP.

On 01/09/26, LPA Partoza continued with the investigation and interviewed 3 staff (S1 to S3). S1 stated that he/she is not aware of R1s pressure injury on the foot, however, remembers R1 having a pressure injury prior to moving to MC, and it was on the back, it is no longer there. S2 stated R1 gets upset with care and is aggressive. S2 stated R1 can bruise easily because of his/her heart medication. S2 stated R1 came from a different facility, and he/she had a pressure injury on the back at that time. S2 stated that he/she remembers that R1 developed a pressure injury on his/her heel, but not sure how. S2 stated that caregivers elevate R1s legs every two hours. S2 stated when the medication technicians (MT) on duty was notified by the care staff of R1s wound, MT called the doctor and notified RP right away S2 stated R1 has a lot of skin problems on his/her legs, and memory care staff take care of R1. S2 stated "currently, R1s pressure injury is healing well." S3 stated that "R1 is aggressive especially during his/her ADLs, R1 likes to punch, kick and flay his/her arms to staff. It will take three care staff to change R1." S3 stated he/she "I put cream on R1s rashes. R1 skin is very sensitive. When he/she move R1 foot to elevate, R1 screams because it's painful. R1 will say ouch, ouch whenever they move or reposition his/her foot."

On 01/27/2026, LPA interviewed 1 staff (S4). S4 stated he/she has not seen a staff neglect a resident that may have caused a pressure injury. Staff give residents proper care and turn residents who are bed bound every two hours to avoid rashes. S4 stated R1 is aggressive and says something inappropriate, pinches and taps staff. S4 stated it does not hurt but for the most part R1 is nice. S4 stated that as caregivers they do body checks and if they see something that was not there before, they report to the MT on duty. For any life threatening situation they call 911. ---- page 2 of 4