complaint·December 13, 2023

any pressure injury including at end of life. Witness interviewed confirmed this as well. Both staff members indicate at time of complaint, resident was ambulatory, always out of the resident’s room and participating in socialization. Hospice notes confirm resident’s ambulatory status. Physician report dated 09/15/2020 indicated a diagnosis of Dementia with no documentation of any pressure injury or history of pressure injury. Resident’s Needs and Care Plan at time of complaint has no documentation of skin breakdown or wound care. Based on record review and interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.