complaint·October 25, 2025

Interviews conducted with staff revealed, R1 was receiving services from a home health agency. Per staff, they followed home health nurse’s recommendations, provided assistance to R1 by repositioned at least every two hours. Per staff, R1 was cognitive and would choose to sit in R1’s wheelchair daily to be able to move around. Interview conducted with responsible party revealed, responsible party visited the facility and had no concerns of neglect from the facility staff. Documents reviewed revealed, R1 was admitted to receive home health agency services on 3/3/25. Per home health records dated 3/3/25, R1 had a stage 2 wound to left buttock, and will be provided care by a skilled professional to perform wound care three times a week. Wound care order dated: 3/3/25 notes skill professional “to provide wound care to stage 2 pressure ulcer on left buttock.” Wound care order dated: 3/15/25 notes R1 was observed with a change in condition unrelated to the wound and send to the hospital. Per medical records R1 was admitted to the hospital on 3/15/25. Hospital assesses the wound on 3/16/25 as a stage 2 wound to the right buttocks and unstageable to the left buttocks. Although, the wound to the left buttocks was noted as unstageable on 3/16/25 R1 was receiving care by a skill professional under home health care since 3/3/25. Documents reviewed do not corroborate the allegation. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.