complaint·July 21, 2022

On 11/30/21, home health visits facility for wound treatment. On 12/1/21, R1 admitted on hospice and wound was diagnosed as a Stage 3. Care plan was developed by hospice agency. Notes indicate it is unclear how the wound developed since R1 is ambulatory and very active. Interviews conducted with staff revealed that they were aware of the wound and R1’s skin condition. Facility staff report communicating with the family and medical professionals about R1’s skin condition. Based on the information obtained, there is no evidence to suggest facility neglected R1 which resulted in pressures injuries. Therefore, the allegation is unsubstantiated. Allegation - Staff did not seek medical attention for resident in a timely manner. Facility notes, physician’s orders and medical records revealed facility documented any changes of condition to R1. R1 obtained proper care for skin issues by being prescribed ointments/creams and wound care. There was no evidence that facility neglected any medical issues. Based on the information obtained, the allegation is unsubstantiated. Allegation - Staff did not give resident medications as prescribed. Medication records indicate R1 obtained all medications as prescribed. Physician’s orders indicate R1 obtained creams for skin issues and wound care. Facility did document when R1 was agitated and aggressive with staff and would not allow skin treatments. Home health also documented aggressive behavior when attempting to evaluate R1’s skin. There was no evidence to suggest R1 did not obtain medications as prescribed. Therefore, the allegation is unsubstantiated. Allegation - Staff did not ensure that resident's hygiene needs were met. Staff documented when R1 would refuse a bath and would be aggressive with staff. Staff interviewed also confirmed R1 was aggressive at times. Staff indicated if R1 was having less behaviors one day they would assist R1 with a bath even though R1 was not on the schedule that day. Based on the information obtained, the allegation is unsubstantiated. Allegation - Facility is retaining a resident that requires a higher level of care. R1 was diagnosed with a Stage 3 wound which was being treated by medical professionals including a hospice agency. Based on observations, interviews conducted and records reviewed, R1 was fully ambulatory and often walked around the facility unassisted. None of the records reviewed revealed that R1 was diagnosed with a condition that was unsuitable for this type of facility. Based on the information obtained, there was no evidence to prove the allegation. Therefore, the allegation is unsubstantiated. R1 has advanced dementia, therefore R1 was not interviewed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.