complaint·February 18, 2026

On 9/18/2025 the Department conducted the initial complaint investigation visit. On 9/18/2025, 10/6/2025 the Department interviewed the Executive Director (ED), 2 Staff (S1 to S2) and 2 Witnesses (W1 and W2). ED states residents are checked on by staff according to each resident’s care plan. On 9/19/2025, 9/23/2025, 9/30/2025, the Department interviewed 2 Staff (S1 to S2). 1 Out of 2 Staff state the facility has enough staff to meet residents’ needs. S1 states the facility is short staffed, and residents don’t get his/her showers. S1 did not provide additional information regarding these incidents. S2 states the facility is not short staffed, and there has never been a time he/she did not respond to or assist residents with his her care needs. On 9/30/2025 and 10/6/2025 the Department interviewed 2 Witnesses (W1 and W2). W1 states ‘there is no routine to staff checking on residents.” W1 did not provide additional information. W2 did not provide additional information regarding staffing. Review of R1’s progress notes dated 9/17/2025 to 9/23/2025, R1 was observed by facility staff, and medications were administered per doctors’ orders. No noted incidents of staff not responding to residents call button. Resident sustained a pressure injury while in care. On 9/18/2025 the Department interviewed Reporting Party (RP). RP states a resident, referred to as R1, sustained a pressure injury on 9/18/2025. RP states he/she received a call from facility staff regarding a ‘wound’ observed on R1 on 9/18/2025. RP states R1’s care team was informed (physician and responsible party). On 10/6/2025 the Department interviewed the Executive Director (ED) ED states R1 is receiving home health care since August 2025. ED states if home health agency staff observe any wounds or pressure injuries, they are to inform the facility. ED states home health agency reported on 9/12/2025 and 9/16/2025 R1’s skin was ‘clear.’ ED states the facility became aware of R1 having a wound on 9/17/2025. ED states R1 care team and responsible party were notified of the wound on 9/17/2025. ED states on 9/19/2025 the facility spoke with home health care and was informed that home health care did not communicate the wound due to home health care calling the wrong number (facility). ED states this incident is documented on R1’s progress notes. Page 2 of 3 On 9/30/2025 and 10/6/2025, the Department interviewed 2 Witnesses (W1 and W2). W1 states he/she observed R1’s skin to be ‘clear’ on 9/12/2025. W1 states he/she became aware of R1’s wound on 9/17/2025 and R1’s doctor was informed. W1 did not state how he/she became aware of R1's wound. W1 states facility staff were informed on 9/17/2025 of R1’s wound. W2 states he/she did not observe a wound on R1. W2 states he/she was informed of the wound by RP on 9/19/2025. W2 did not provide additional information. LPA reviewed R1’s progress notes dated 9/17/2025 to 9/23/2025. On 9/17/2025 facility staff observed a wound on R1's skin, and R1’s care team was notified (physician and responsible party). On 9/19/2025 the facility followed up with R1’s responsible party, physician and home health agency regarding the care for R1's wound. Per progress note on 9/19/2025, “home health returned call, stated they communicated wound to PCP (physician) but not to care team. Per coordinator they were calling the wrong number.” Review of home health progress notes for R1 dated 8/28/2025 to 9/22/2025, notes on 9/12/2025 R1 skin's was observed as ‘intact.’ On 9/16/2025, R1’s skin was observed to have “no open areas or non-blanchable redness.” On 9/19/2025 home health documented a wound for R1, “R1’s wound had increased severely over the last 2 days.” Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited during today’s visit. An exit interview was conducted, and a copy of this report was provided. Page 3 of 3 END OF REPORT.