Complaint·June 11, 2026

Records reviewed showed that R1 had a history of multiple chronic medical conditions, including diabetes, vascular disease, severe anemia, and poor circulation. Medical records indicated these conditions significantly affected the resident's ability to heal and increased the risk of developing pressure injuries. R1 was admitted to the hospital on October 21, 2025, due to abnormal laboratory results, severe anemia, weakness, and ongoing wound concerns. Hospital records reviewed showed that multiple unstageable pressure injuries were identified during the hospitalization. Hospice records further documented that, prior to the hospitalization, hospice had been providing wound care treatment to R1 for Stage II and Stage III pressure injuries. Hospice records contained physician orders, regular nursing visits, wound assessments, and ongoing monitoring of the resident's skin condition. Facility staff were responsible for monitoring R1's condition, reporting changes, and following medical recommendations. LPA interviewed R1's hospice case manager, who stated that R1's wounds were not caused by a lack of repositioning and that R1's chronic medical conditions played a significant role in the development and healing of the wounds. The hospice nurse reported that facility staff regularly communicated changes in the resident's condition, reported concerns when dressings became soiled, and contacted hospice as needed. The hospice nurse stated there were no concerns that the facility neglected the resident's care. LPA also reviewed hospital records. While hospital staff documented multiple pressure injuries and expressed concern regarding the severity of the wounds, the records did not conclude that the wounds were caused by neglect by facility staff. The records showed that R1 was already receiving wound care services prior to hospitalization. During a screening documented in the hospital records, R1 denied being abused, neglected, or mistreated by the facility. Although the investigation confirmed that R1 had multiple pressure injuries, the evidence obtained did not establish that facility staff caused or contributed to the wounds through neglect. The evidence showed that R1 had significant underlying medical conditions affecting wound healing and was receiving ongoing treatment from hospice and other medical providers. (Report continued on LIC9099-C) Based on the information obtained during the investigation, the allegation is deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report and the Confidential Names List were provided to the facility.