Complaint·April 29, 2026

Staff neglect resulted in resident sustaining multiple pressure injuries. - UNSUBSTANTIATED Based on R1’s care plan and care needs, R1 was independent in their care. R1 needed standby assistance in the shower. R1 was able to conduct all other aspects of their care on their own. On 8/20/2025, staff were cleaning R1 after R1 had a toileting accident and noted R1 had black tar like stool and blood on their rectum, it was also noted R1 had a black toe on their right foot. Staff were not aware of the black toe prior to this. Per R1’s care plan staff had no expectation to perform body checks on R1. Staff would not have seen the toe as R1 showers and dresses themselves. R1 is also able to communicate their needs and voice if R1 is in pain. R1 voiced no concerns nor complaints of pain. On 8/20/2025, R1 was admitted to Renown Regional Hospital on 8/20/2025 due to “Acute osteomyelitis of toe of right foot.” R1 was also admitted due for gastrointestinal bleeding. R1 received wound care treatment due to “noted bone exposure.” On 8/22/2025, “Patient was taken to the OR by orthopedics on 8/22, underwent disarticulation of a necrotic second toe.” It was also discovered R1 had pressure wounds to their “Pretibial Proximal Left” (Amputated leg), and “Right Lateral Hallux” (amputated toe). R1 also had “Buttocks incontinence dermatitis” (showed a red and inflamed area around their buttocks which turned white). R1 was discharged on 8/26/2025 to Lassen Nursing and rehab. Based on R1’s care plan and their independence in care, the staff had no reasonable expectation to perform body checks on R1. R1 voiced no concerns nor voiced they were in pain. The preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated. Continued on LIC9099-C Staff did not seek timely medical attention for resident. - UNSUBSTANTIATED On 8/20/2025, while conducting morning incontinence care, staff noted R1 had a black tar like stool and blood on their rectum. It was also noted R1 had a black toe on their right foot. After both of these concerns were found, staff immediately called 911 and R1 was sent to the hospital. Prior to the discovery of the two concerns, there was no indication R1 needed any sort of medical intervention. R1 cares for their own activities of daily living (ADLs) and has standby assistance with showers. R1 can communicate any concerns or if they are in pain to staff and did not disclose any issues. Based on the totality of the evidence found, the preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated. Staff did not inform residents’ representative of a change in resident's condition. - UNSUBSTANTIATED Prior to 08/20/2025 when staff called 911 and R1 was sent out to the hospital for blood in stool and a black right toe, staff were not aware of a change in condition for R1. Prior to the discovery of the two concerns, there was no indication that R1 needed any sort of medical intervention. R1 cared for their own ADLs and had standby assistance with showers. R1 is able to communicate any concerns or if they are in pain to staff and did not disclose any issues. Per R1’s care plan staff had no expectation to perform body checks on R1. LPA reviewed an incident report dated 08/20/2025 reporting that staff discovered R1 in bed incontinent of large black stool. Noted visible blood on rectum as well as a bloody back right toe - called 911 and resident was transported to hospital for evaluation. Incident report includes RP Krissy notified, PCP notified. Emergency Contact RP Notified via voice mail - return call with Krissy. LPA searched database for other incident reports for R1 and none were reported. Based on the totality of the evidence found, the preponderance of the evidence has not been met; therefore, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Executive Director Brian Moore.