Complaint·February 19, 2026

Allegation: Staff neglect resulted in pressure injuries to a resident in care. It is alleged that staff failed to reposition R1 as required, resulting in the development of possible pressure ulcers/bedsores. During staff interviews, staff reported that their duties include providing direct care to residents, assisting with activities of daily living, repositioning, incontinence care, housekeeping tasks, meal assistance, and medication administration. Staff consistently stated that facility procedure requires repositioning residents every two hours and that caregivers collectively share responsibility for ensuring repositioning is completed. During R1 interview, R1 stated she is changed approximately every three hours but is not consistently repositioned and reported that her pressure sores developed after admission to the facility. During resident interviews (R2–R5), residents reported being satisfied with the care provided by staff. Residents stated that staff assist with repositioning or provide help when needed and reported that staff are kind and responsive. One resident reported occasional delays in assistance, particularly for restroom needs, while the remaining residents reported no concerns regarding care. During witness interview (W1), W1 reported concerns regarding the development of R1’s pressure-related skin issues following admission. W1 described notifying R1’s physician, requesting increased repositioning from facility staff, and expressed uncertainty regarding the consistency of repositioning practices. W1 also reported encouraging R1 to participate in her own care when possible. During witness interview, W2 provided information regarding home health services for R1. W2 was contacted by telephone and reported that a home health nurse visits R1 three (3) times per week to assist with care. W2 confirmed they are currently treating one (1) wound only. W2 confirmed they will be emailing the facility all skilled nursing visit notes from start of care 12/25/25 to date. (continued on 9099C) LPA observed a Physician’s Report dated 12/15/25 indicating that R1 was admitted to the facility with a healing Stage Two sacral wound. R1’s admission date was 12/22/25. Based on Home Health notes, R1 began receiving services on 12/25/25. Per a Home Health note dated 01/28/26, nurse documented that the wound continued to show signs of healing. A wound assessment completed on 02/02/26 noted the wound had improved to Stage One. Home Health notes dated 12/31/25 to present reflect consistent care and continuous progress in wound healing. Based on the investigation conducted, which included interviews with staff, witnesses, and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held, and a copy of this report was provided.