Complaint·May 21, 2025

From 01/15/25 to 02/28/25, IB conducted continuous interviews with facility administrator, staff and witnesses. These interviews reveal that R1 was not being repositioned as instructed on R1’s care plan. Further interviews with witnesses reveal that although staff took care of R1, staff did not consistently reposition R1 as instructed on their care plan. Moreover, it was also revealed that facility staff were not in communication with the home health agency regarding the progress of R1’s wound. On 01/14/25 and 01/31/25, IB received R1’s medical records and the following were reviewed: · R1 was admitted to the facility on 11/29/24. · Home Health was in place to treat R1 for Massive Associated Skin Damage (MASD). · On 12/05/24, there was some skin discoloration, but was assessed on 12/06/24 to be Stage I. · On 12/09/24, there was home health orders to provide wound care. · On 12/14/24, medical records and picture documents stage 3 in sacral area. · On 12/16/24, despite treatment from home health to address R1’s wounds, R1’s wounds progressed. · On 12/16/24 to 12/17/24, R1’s wound to the coccyx and heel progressed and was diagnosed by home health to be stage 3 and 4. · 12/16/24 to 12/20/24, with documentation and the licensee’s knowledge of the wound’s progression to the coccyx and heel, R1 was still retained at the facility for another five days. · On 12/21/24, R1 was eventually transferred to the hospital for an unrelated medical emergency. Based on the information obtained, there is sufficient evidence that the licensee retained R1 at the facility with a prohibited health condition. Therefore, the allegation is Substantiated. Citations issued on the 9099D. Licensee advised of possible Civil Penalty and Enhanced Civil Penalties (ECPs) may be assessed.