complaint·March 24, 2026

During today’s visit, the LPA conducted a physical plant tour at 10:02AM and no immediate concerns were observed. The following was then determined: Allegations: “Due to staff neglect, resident sustained pressure injuries” and “Staff retained a resident with a prohibited health condition” It was reported that Resident #1 (R1) sustained pressure injuries while under the care of the facility in addition to the facility admitting R1 with an existing unstageable pressure injury. On 10/25/2025, R1 was transported unannounced to The Residences At Royal Bellingham from a previous licensed facility. Upon admission, R1 was assessed and noted a sacral area that was reportedly only red in discoloration at that time. On 10/29/2025, R1 was transferred to the hospital for recurrent nosebleeds and returned to the facility later that evening. The following day, 10/30/2025, staff observed R1’s sacral area had opened and arranged transportation to the hospital for further evaluation and treatment. Staff #1 (S1) reported that prior to the hospital visits, they had provided R1 with two (2) showers and did not observe any open wounds. The Facility Manager stated that staff provided care as required, including repositioning R1 every two (2) hours. Interview with R1 revealed no concerns regarding their care and stated that staff met their needs. When asked about their pressure injuries, R1 reported that they had existed for a long time. Physician’s Report dated 07/22/2025 documented that R1 was bedridden with diagnoses including hemiplegia and hemiparesis following infarction affecting the left non-dominant side, as well as protein-calorie malnutrition. Hospital records dated 10/31/2025 documented right lower extremity cellulitis and three (3) exposed subcutaneous chronic non-pressure ulcers located on the right hallux, right plantar forefoot, and the right heel. R1 subsequently received wound care consultations addressing only the lower extremity wounds; no documentation confirmed the presence of an unstageable sacral wound. Based on interviews and record review, R1 had pre-existing chronic non-pressure ulcers and hospital documentation did not confirm the presence of an unstageable sacral wound. The facility additionally took appropriate action by seeking a higher level of care when R1’s sacral area showed signs of deterioration. Although the allegations may have happened or are valid, there is insufficient evidence to prove that staff neglect contributed to R1’s condition, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.