complaint·March 16, 2026

Regarding the allegation: Staff neglect resulted in resident sustaining multiple pressure injuries. It is being alleged that resident #1 (R1) was neglected by staff at the facility and developed several wounds. LPA interviewed two (2) staff that confirmed R1 was receiving wound care from Star World Home Health. Staff #1 (S1) confirmed that R1 was receiving home health services two (2) -three (3) times a week and home health never informed S1 that the wounds were not getting better. LPA also interviewed two (2) staff at Star World Home Health that confirmed R1 was previously receiving wound care from Grand Valley Health Care Rehabilitation Center. LPA requested notes from Star World Home Health that noted R1 had a left and right pressure injury and R1 also had a stage 3 wound on their sacrum. When LPA interviewed both Home Health staff, they both stated, “that R1 appeared to have a stage 2 on their sacrum but the notes confirmed Home Health marked the wound as a stage 3. LPA requested medical records from Kaiser Permanente where it confirms that on 09/02/25, R1 had gone for emergency services and was referred to a Skilled Nursing Facility (SNF) for wound care on the sacrum and right and left heels, physical therapy and occupational therapy. R1 did not get admitted to the above facility until 12/02/25. R1 was then taken to the hospital on 02/02/26 where the medical records from Kaiser Permanente noted the same wounds as of 09/02/25, wound to the sacrum area and right and left heel. LPA also interviewed R1’s daughter and R1’s daughter stated, R1 did not get admitted to the above facility until 12/02/25. R1 was then taken to the hospital on 02/02/26 where the medical records from Kaiser Permanente noted the same wounds as of 09/02/25, wound to the sacrum area and right and left heel. LPA also interviewed R1’s daughter and R1’s daughter stated, “I have no concerns with the facility and/or the staff. My concern is with the Home Health that provided care for R1 because they were not really communicating with us. They should have told us that the wounds were not getting any better or were remaining the same so R1 could have been sent back to the Skilled Nursing Facility.” Based on the LPA's medical record review, home health notes, file review and interviews conducted, the allegation(s) for physical abuse is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) issued, and a copy of this report was given to the Administrator.