complaint·July 1, 2025

Allegation: Resident developed multiple pressure injuries in care due to staff neglect It is alleged that a resident developed multiple pressure injuries in care due to staff neglect. Regarding this allegation it is reported that Resident #1 (R1) was not moved for seven (7) months, and they developed pressure injuries rendering R1 wheelchair bound. During interview with R1, R1 was not able to provide, date, time or names of staff involved, at times mentioning different facilities. Interview with Administrator revealed that R1 was a resident but that R1 left in March of 2023. According to Administrator R1 was presenting with lethargy and was sent to the hospital where the provider recommended R1 go to a skilled nursing facility due to R1 needing a higher level of care facility. Per Administrator R1 did not have wounds on them when R1 left the facility in March of 2023. The Administrator also stated that when R1 was admitted to the facility, R1 was already in a wheelchair. LPA was able to interview four (4) additional staff that were present at the time that R1 was present, and they stated that R1 did not have wounds and that R1 was compliant with taking their medication. Staff stated that R1 was sometimes difficult because R1 refused grooming at times but that R1 was in good health for the most part during R1’s stay at the facility. Furthermore, it was revealed by the Administrator that during the working shift at night there is an internal policy to make rounds every two (2) hours so that staff can check on residents and make sure that they are all doing ok, to include assistance with repositioning if needed. LPA interviewed ten (10) residents, and they all revealed that the facility takes good care of them, the staff are nice and that they have no concerns about lack of care being provided. LPA Casillas reviewed R1’s file and there was no indication of any wounds being present during R1’s approximate three (3) year stay. During the record review LPA also found that R1 did in fact already use a wheelchair upon admission to the facility. LPA also reviewed staff files and there were no disciplinary actions taken against staff pertaining to neglect. Therefore, based on LPA observations, record reviews and interviews, this allegation is deemed unsubstantiated. Continued on LIC9099-C Allegation: Facility staff handled resident in a rough manner It is alleged that facility staff handled resident in a rough manner. Regarding this allegation it is reported that facility staff turned R1 in such a manner that “they almost dislocated my hip”. Interview with R1 revealed that R1 does not recall the date, time or names of the staff involved and at times R1 kept referring to other facilities. R1 also stated that they do not have medical records to offer LPA, refusing to provide additional information. Interview with Administrator denied the allegation stating that R1 was difficult at times as far as grooming went, but that R1 was constantly checked on to make sure that R1 was comfortable. Administrator stated that during R1’s stay at the facility, there were no reports made by R1 pertaining to R1 being mistreated or reported by anyone else. Administrator states that concerns about such matter are taken very seriously and had they been made aware, it would have been taken care of immediately. Interview with four (4) staff corroborated Administrators’ statements denying that R1 was mishandled. Staff revealed that they were very much in tune with R1’s needs to the point that when R1 displayed any concerns, they were all made aware and worked as a team to help R1. LPA interviewed ten (10) residents, and they all stated that the staff at the facility are caring and would never hurt them. LPA reviewed records and could not find any documents indicating R1 being mistreated. Therefore, this allegation is deemed unsubstantiated. No citations issued, exit interview conducted. Copy of report given to Administrator.