complaint·October 6, 2022

On 07/05/22 R1 was in pain due to the fall and paramedics were called to transfer R1 to the hospital. This fall and hospitalization was reported to CCL on 07/09/22. While hospitalized doctors observed wounds on R1’s legs and feet and alleged the wounds were obtained during R1’s stay at the facility. On 08/24/22 Investigator Real conducted a visit at the facility to interview staff, residents and collected documents pertaining to the investigation. Documentation review and interviews determined that R1 moved into the facility on 06/30/22 from a skilled nursing home. R1 already had wounds on their legs and feet prior to residing at Cedars Assisted Living. According to interviews R1 was receiving home health wound care at the facility and was assessed by a nurse prior to the fall that occurred on 07/04/22. On 07/05/22 R1 was admitted to the hospital due to pain obtained during the fall on 07/04/22. Doctors observed the wounds and reported their observation to the Department. According to interviews by staff, R1 and R1’s family, these wounds were not obtained during R1’s stay at the facility. Therefore, based on the information gathered during this investigation, “Resident sustained multiple pressure injuries while in care”, is deemed Unsubstantiated. No deficiencies cited. Exit interview conducted. Report signed and delivered. Appeals right delivered.