complaint·February 6, 2026

R1 was hospitalized and passed away in August 2021. LPA conducted review of wound care progress reports dated 03-08-2021 and 08-02-2021 which revealed that R1 had three (3) pressure injuries. However, the wound care progress reports did not reveal any reason how R1 developed multiple pressure injuries. LPA conducted interviews with the Licensee and Staff #1 (S1), all of whom stated that R1 had received two (2) hour repositioning during R1’s residence at the facility. LPA attempted to obtain R1’s resident file during the facility visits. R1’s resident file was unavailable. LPA’s interview with the Licensee revealed that R1’s resident file was no long available due to expiration of resident records retention period. LPA's records review and interviews conducted did not reveal if the facility staff's neglect played any part in R1 developing multiple pressure injuries. The Department’s investigation did not provide enough information to corroborate the allegation that resident developed multiple pressure injuries while in care. This allegation is unsubstantiated. It was alleged that facility staff is not following residents prescribed diet. Information received indicated that staff provided wrong kind of nutrition formula to Resident #1 (R1). LPA’s records review revealed that R1 had a gastrostomy tube, and R1’s hospice agency was responsible for ordering and delivering the nutrition formula to the facility. LPA conducted interviews with the Licensee and Staff #1 (S1), all of whom stated that only the correct nutrition formula was provided to R1 following the instruction from R1’s hospice agency. Both the Licensee and S1 stated that R1 had received only the correct nutrition formula delivered by R1’s hospice agency. The Department’s investigation did not provide enough information to corroborate the allegation that facility staff is not following residents prescribed diet. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.