complaint·April 17, 2025

In regards to the allegation Due to neglect, resident sustained wounds, based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, leading to the Resident R1 to sustain wounds while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the staff S2 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. All the staff interviewed, stated that R1 would have her socks changed daily and she would have showers twice a week. Per the Hospice Nurse and the Home Health Nurse , they both stated that the facility appeared to not be neglectful of R1. They did not believe the facility was neglectful with R1's level of care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff did not provide timely medical care for resident, Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, due to Staff not providing timely medical care for the Resident R1 while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the Staff S1 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff are not ensuring residents hygiene needs are met, based on interviews conducted and information gathered Resident R1 revealed that she felt happy and safe at the facility. R1 added that she enjoyed playing games with the staff and other residents, and there was nothing she disliked. R1 added that she would receive two showers weekly. R1 stated that staff would change her socks daily. R1 stated that she has a lot of nurses who would tend to her weekly. Interview with Hospice Agency Representative who stated that “I’m a patient care advocate and I don’t hesitate to call APS, but I don’t think they (the facility) was being neglectful.” Stated that R1's foot issue was addressed by a home health agency, and she believed that the home health agency would be responsible for caring for R1's foot. Interview with Home Health Agency representative who stated that she did not recall any foot issues with R1 as she appeared well cared for and well dressed. Her room was cleaned, and it seemed as she was showered regularly .Could not recall seeing R1 in socks as she would typically wear sandals barefoot. Interview with Staff who stated that R1 was cared for very well by the facility and other agencies. Stated she took 2 showers each week and did not go without socks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.