complaint·April 28, 2026

Due to staff neglect, resident sustained pressure injuries Review of records and interviews indicates that R1 was receiving ongoing medical oversight from multiple external providers while residing in the facility. R1 was on home health services that visited the facility three times per week to provide skilled nursing care, including wound management. In addition, R1 received consistent wound care services through InnovAge on Fridays, where the wound was being actively monitored and treated by licensed nursing staff. Documentation indicates R1’s care needs were being addressed through coordinated medical services outside the facility staff. R1 was later admitted on hospice care after being enrolled through home health services beginning 02/20/2026. Based on the information obtained, there is insufficient evidence to demonstrate that facility staff did not provide care and supervision in accordance with Title 22, or that any action or inaction by facility staff directly resulted in or contributed to the development or worsening of R1’s injuries. Therefore, the allegation is determined to be UNSUBSTANTIATED. Exit interview conducted. Report left with facility.