complaint·March 19, 2025

Resident developed pressure injuries while in care. Interview with W1 revealed that R1 did not develop pressure injuries during the time R1 was on hospice care. Interview with staff revealed that R1 was repositioned every 2 hours. R1's home health notes indicated that R1 was high risk of pressure sore, but did not indicate that R1 had pressure sore. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted with Janice Gombio. A copy of this report provided.