complaint·September 29, 2025

Allegation: Facility staff are not properly turning resident resulting in pressure injury. The complaint alleges that staff are not moving Memory Care Unit resident (R1) often, and as a result in mid August 2025 the resident developed a new pressure injury on the resident's bottom/coccyx area. It was reported that R1 has past history of pressure injuries, with the most recent pressure injury being in their heel and toe. A total of 7 staff were interviewed, of which all denied the allegation. None of the residents interviewed acknowledged the allegation. Staff interviews revealed that in mid-August 2025 a caregiver reported to the Memory Care Unit lead staff/med-tech that R1 had redness and a small opening in the bottom area, whom then contacted primary care providers and family. Per document review, on August 20, 2025 a SCAN Nurse Practioner submitted a home health referral order for wound care services of the toe and coccyx skin breakdown. Picture evidence was obtained. The picture depicts redness with slight skin abrasion located in R1's bottom. Records indicate R1 is dependent for all ADL's due to advanced Dementia. According to staff, repositioning procedures have been followed and there is currently no pressure injury in R1's bottom. During today's visit, the SCAN Nurse Practioner was on-site; therefore LPA requested they conduct a full body assessment to determine if there is a pressure injury in the bottom/coccyx area. The nurse reported back to LPA that there is no redness or open wound to the coccyx and bottom area. There is insufficient evidence to support the allegation. Allegation: Facility staff are leaving resident in bed for extended periods of time. It is alleged that on September 24, 2025, at approximately 6:30 PM, resident (R1) was observed in their bed with a napkin with crumbs on the resident's chest, indicating the resident was fed dinner in their bed instead of being wheeled to the dining room in the resident's Geri chair. Memory Care Unit residents stated they are not left in bed for extended periods of time and are checked on frequently. According to staff interviews, caregiver staff are responsible for getting R1 up in the morning, transferring them to their Geri chair, taking the resident to the dining room for breakfast meal, and then to the activities room. Staff stated that R1 is typically put to bed for a nap after lunch time, and then transferred to their Geri chair prior to dinner meal time in the Memory Care Unit dining room. Staff interviews revealed that on 9/24/25, R1 was taken to their room for a nap after lunch. PM caregiver staff used the Hoyer lift on R1 at approximately 3 PM, and noticed that the resident's right outer bottom cheek had redness and the resident was sound asleep. The caregiver decided to keep the resident in bed because they thought the redness may have been a result of Geri chair use earlier in the day. According to the PM staff (S1) the resident was fed dinner in their room that day, continued checks and repositioning was performed, there was no neglect, and it was an isolated incident. Per document review, the Physician's Report states R1 is bedridden due to both physical and mental condition, spends all day either in bed or Geri chair and requires 2-person assist transfers are required with use of Hoyer lift. Therefore, the allegation cannot be supported. 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 . Exit interview and a copy of the report was issued to Health & Wellness Director Laura Garcia.