complaint·September 12, 2025

to the hospital with multiple wounds, including a stage 4 pressure injury (PI) due to facility neglect. It’s not reported if R1 was receiving home health or hospice care to treat these wounds. The following is a timeline of events taken by LPA Cava during the course of this investigation. 12/17/24: LPA Cava interviewed the administrator and Staff 1 (S1), who both deny neglect. Both stated R1 was admitted on 11/15/24. Both stated R1 was receiving Hospice Care at admission. Both confirmed there were (PIs) present, but (PIs) were being treated by Hospice. Both confirm communication with Hospice daily regarding R1’s (PI). Both state on or around 12/06/24, R1’s (PIs) did progress, and followed hospice advise to have R1 transferred to the hospital. 12/17/24: LPA Cava reviewed facility records pertaining to R1. Record review reveal R1’s admission on 11/15/24. R1’s Pre-Placement Appraisal and Appraisal reveal (PI’s), but no stages indicated. 12/17/24: LPA interviewed R1’s family, who could not confirm when and where R1’s wounds developed and progressed. 07/18/25: LPA Cava conducted a subsequent visit to the facility to conduct additional interviews with both administrator and S1. Both repeated and confirmed information provided during initial visit. Contact was made to interview R1’s hospice nurse. According to hospice nurse, hospice was ordered for R1 at admission to facility. Hospice nurse confirmed R1 had (PIs) at admission. Hospice nurse stated part of the hospice care plan was to provide wound care for R1’s (PIs). Hospice nurse acknowledge that hospice care will end service if R1 was sent to the hospital. Hospice nurse stated R1’s wounds were not getting better on 12/06/24 and had ordered for R1 to get transferred to the hospital for a higher level of care. LPA requested for copies of R1’s hospice records. 07/21/25: LPA Cava received R1’s hospice records. 09/07/25: LPA reviewed the hospice records. Per review, hospice was ordered on 11/15/24. Hospice record documents a stage 2 and unstageable (PIs). Hospice records also indicate wound care for these (PIs). On 11/22/24, hospice records indicate visit with R1. Hospice documentation reveal R1 refused examination and treatment. Today, subsequent visit made to close out investigation. Interviews with five (5) of five residents deny any neglect and lack of supervision. Interviews with administrator and S1 remain consistent with interviews conducted during previous visits. Based on information obtained, although there is indication of Pressure Injuries (PIs) to R1 at admission to facility, there is evidence that hospice care was ordered to treat these wounds. Evidence obtained could not prove that due to facility neglect, R1 sustained multiple injuries, including a stage 4 Pressure Injuries. Therefore, the above allegations are deemed Unsubstantiated at this time.