complaint·October 15, 2025

Allegation: Staff did not ensure resident received proper wound care It was alleged that R1 had an open wound below his/her right knee and that ''barrier cream" was put onto the open wound by the facility staff. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that R1 had no pressure wounds. However, due to R1’s medications and dry skin, R1 developed abrasions (on legs) caused by scratching. LPA was informed that the staff redirects R1 and reminds R1 not to scratch his/her legs. LPA was also informed that no cream/ointment was ever prescribed nor applied to R1’s legs. The staff treats R1’s scratches / wound below the knee with soap and water. Interview with two staff members confirmed the statement provided by the Administrator and both staff interviewed denied the above allegation. During the initial visit, LPA observed R1’s legs covered with abrasions caused by itching. LPA also observed proper first aid, like covered scratches with clean dressing placed on R1’s right leg to prevent it from getting infected. Lastly, interview with R1 also confirmed that the staff always provides proper care by cleaning his/her legs with soap and water and no ointment/cream has been ever applied to R1’s leg. Therefore, based on interviews and LPA observation this allegation is deemed Unsubstantiated, at this time. Allegation: Staff did not ensure resident was kept clean It was alleged that R1 was covered in old feces upon arrival to the hospital. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff members. All parties interviewed denied the above allegation and informed LPA that before R1 was taken to hospital S1 changed R1’s diaper/pull-ups. Interview with R1 also confirmed that prior to paramedic’s arrival on 01/29/25, S1 cleaned and changed R1’s diaper/pull-ups. Additionally, LPA conducted an interview with the facility witness/visitor and was informed that they visit the facility at least twice a week and observed all residents to be clean and well taken care of. Two (2) out of three (3) residents interviewed expressed no concern regarding this allegation. Lastly, during the initial visit, LPA observed the facility common areas and resident rooms were clean and free of odor. Therefore, based on interviews and LPA observation this allegation is deemed Unsubstantiated, at this time. No deficiency issued. Exit interview conducted and copy of this report signed and delivered.