complaint·November 3, 2025

The investigation revealed the following: Allegation - Resident sustained multiple severe pressure injuries due to staff neglect. It is alleged that Resident #1 (R1) was observed with multiple pressure injuries that were not reported until R1 was hospitalized on 6/24/25. It was reported that resident has a right hip unstageable, right heel unstageable, sacral coccyx deep tissue, and right elbow deep tissue. Per the administrator and staff, R1 was receiving home health wound care treatment for the hip and heel. Staff stated they also informed the home health nurse of the redness observed on the lower back. LPA obtained and reviewed documents for R1. Home health documents showed that on 6/20/25, the nurse conducted a head-to-toe assessment on R1 and did not observe any new wound at that time. The nurse performed wound care on the right hip, right heel, and lower back. Six (6) out six staff who provide care to residents stated that when they observe any redness on a resident, they report it right away and determine the care plan. Staff also stated they will reposition the residents more often if needed for any wound care. Per the facility staff and home health documentation, there were no indications of a right elbow deep tissue injury before R1 went to the hospital on 6/22/25. LPA interviewed a total of six (6) residents and they all stated that the staff are nice and assist them right away when needed. Based on interviews and documents reviewed, there is insufficient evidence to show that R1 sustained multiple pressure injuries due to staff neglect. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.