Complaint·August 15, 2023

However, on 6/13/2023 R1 was inspected by John Muir Home Visit Nurse Practitioner, who stated during their interview that R1 had a small red mark on coccyx that was not a definite wound. It was also determined that R1 did not have any wounds on the feet, the feet appeared to be dry and scaly. R1’s home health medical records stated that R1’s previous stage one pressure wound on the coccyx healed, then returned, and was probably stage two with slight scab, no exudate. On 7/7/2023, the department interviewed multiple facility staff (S1, S2, S3 and S4), all staff denied seeing pressure wounds on feet. S3 stated that they never saw R1’s feet due to R1 keeping socks on and not letting staff change them. S3 also stated that they observed a pressure would on his lower back. Based on interviews with S2 and S3, staff would rotate R1 every 2 hours. It was also stated during interviews that since R1 was bed bound, it would take 2-4 staff to rotate R1 but facility staff ensured it was done. It was alleged that Facility did not follow resident’s care plan. During record review LPA observed that home health primary provided wound care when R1 had a pressure wound. John Muir Home Health would visit R1 3-4 times a week, every 2-3 months or as needed if the facility or R1 POA called. Based on record review, the facility staff provided assistance with all ADLs and transfers. Based on interviews with S4, R1 did not like to be moved or touched, was difficult and would grab on to the bed when staff tried to rotate him. S3 stated that after staff rotated him, he would move back into the original position and at times would move down causing his feet to touch the foot board. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.