complaint·March 24, 2026

During today’s visit, the LPA and AA conducted a physical plant tour at 10:02AM and no immediate concerns were observed. The following was then determined: Allegations: “Staff leave resident in soiled diapers for extended periods of time.” and “Resident developed a bed sore while in care due to staff neglect.” It was alleged that Resident #1 (R1) was left in their soiled diapers for extended periods, resulting in the development of a bed sore. R1’s Physician Report dated 10/15/2024 documented diagnoses including end stage renal disease, heart failure, and hypertension. Additionally, R1 was receiving hemodialysis four (4) times a week. R1 was noted to be non-ambulatory with a history of skin conditions or skin breakdown and required assistance with bathing, dressing, toileting, and transfers. Interviews with staff indicated that resident diapers are checked and changed every one (1) to two (2) hours. Staff stated that residents also request additional assistance by using their pull cord or calling out. Staff reported that any observed wounds or skin changes are communicated to the med-tech, who assesses the resident and notifies home health or hospice agencies and the resident’s primary care physician. The ED and staff reported conducting a head to toe skin assessment and no skin or wound concerns were observed. The ED further stated that R1 can be uncooperative during care and often refuses assistance. R1 reported that on occasion they have been left in their soiled briefs during the evenings, however it does not occur often. Although R1 expressed conflicts with the evening staff, they reported no overall concerns with the care provided and that staff response times to the pull cords vary. R1 denied having any bed sores during this period and reported only minor diaper-related rashes. Additional resident interviews revealed no concerns regarding incontinent care or wound development. Report Continued on LIC 9099-C Record review further showed that R1 visited the hospital on three (3) occasions: 05/16/2025, 05/19/2025, and 06/02/2025. After Visit and Discharge summaries from these encounters did not document any wounds. However, R1’s Discharge Summary dated 05/17/2025 included a scheduled Wound Care procedure on 06/11/2025, though no additional details were provided. Staff and R1 continued to deny the presence of bed sores. Facility Service Logs between 05/27/2025 and 06/02/2025 documented twenty-eight (28) services provided to R1 including incontinent care, mobility checks, and incidentals. Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.