complaint·May 20, 2025

It was noted that R1 had a loss of appetite, body weakness, and overall cognitive and physical decline. On 12/03/24, a hospice nurse observed Stage 2 injuries on R1’s coccyx and spine. On 12/18/24, a wound care agency assessed R1 to have a Stage 4 injury on their back and a Stage 3 injury on their sacrum. Both injuries were noted to be unrelated to R1’s hospice diagnosis. R1’s hospice care plan was also not updated to include the wound care and excisional debridement performed by the wound care agency. Interview with the administrator at 1:30 p.m. on 01/03/25 revealed staff were instructed to reposition R1 every two (02) hours but not to transfer them due to skin integrity issues. Interview with Staff #1 (S1) at 2:00 p.m. on 01/03/25 confirmed that all staff had been trained by the hospice agency on R1’s care. S1 repositioned R1 every two (02) hours, assisted with incontinence care, and ensured their back and coccyx were dry and free of redness. LPA was unable to interview R1. Interviews with three (03) out of three (03) other residents interviewed revealed they had no issues with pressure injuries. Interview with Resident #2 (R2) at 2:25 p.m. on 01/03/25 revealed S1 reminds them to reposition themselves often. Based on interviews and record review, although R1’s pressure injuries were appropriately cared for by R1’s hospice agency and facility staff, the facility should have applied for an exception to retain R1 in the facility while they received wound treatment unrelated to their hospice diagnosis. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page. Exit interview conducted. Appeal rights discussed. Copy of report provided. Interview with S1 at 2:00 p.m. on 01/03/25 revealed R3 nor any other residents were tied up. S1 further stated that R3 constantly fabricated about staff abuse. Interview with the administrator confirmed R3 was not tied up and the facility had no physician orders for restraints to be used. Interviews with three (03) out of three (03) other residents interviewed revealed they had never been tied up or witnessed anyone tied up. Record review of an incident report submitted by the facility revealed R3 fell on the morning of 12/30/24 and bruised their eye. R3 had no other injuries. Based on observations, interviews, and record review, although the allegation is valid, there is insufficient evidence to verify that staff restrained a resident. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.