complaint·July 31, 2025

During today’s visit, LPA requested copies of resident and staff rosters. At approximately 2:15pm, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Allegation: Resident sustained pressure injuries while in care. It was reported that R1 sustained pressure injuries while receiving care and that the reporting party did not know when the wounds occurred or if the resident was on hospice. The RP also mentioned that R1 did not have any wounds before being placed at the facility. To investigate the allegation LPA conducted thorough review of facility records, hospice agency documentarians, wound care specialist visitation notes, as well as interviews with the facility administrator, two (2) caregivers, and the following were obtained. R1 got admitted to the facility on 8/24/22. Records review revealed that R1 got admitted under hospice care on 11/18/2022 with full consent and agreement from RP. According to the records, R1 developed stage 3 pressure injuries in early October of 2023 and wound care treatment was initiated immediately on 10/6/23. Wound care services were provided in coordination with the hospice agency and a wound care specialist. LPA reviewed records and noted consistent wound assessments, treatment updates, and ongoing monitoring of R1’s condition. Interviews with all staff members confirmed that the facility followed all required protocols, including timely notification of hospice, wound care orders, repositioning R1 every one (1) or two (2) hours, and regular communication with RP. There was no delay in addressing R1’s skin condition, and care was provided in accordance with regulatory requirements. As RP did not specify when the wounds allegedly occurred and was uncertain if R1 was receiving hospice services at that time, the investigation confirms that hospice services were in place and pressure injuries were treated promptly. The interview with two (2) residents confirmed that caregivers do provide adequate care and supervision to all residents and that they witnessed the proper care R1 received while residing in the facility. Residents also stated that RP was visiting R1 frequently, RP was aware of R1’s health condition, and was always thanking caregivers for the best service R1 receives in the facility. Based on the observation, records review, and interviews, there is insufficient evidence to support the allegation that the facility staff neglected care to R1 and failed to provide proper care resulting in pressure injuries. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and report signed and delivered.