complaint·September 4, 2025

The physician's report also indicated R1 could communicate their needs. R1 had a diagnosis of cardiovascular disease, hypertension, and transient ischemic attack. R1's most recent physician's order dated April 21, 2022 included blood thinning medication for R1's conditions. LPA was unable to review home health records as they were not available. LPA interviews with three out of four staff stated they were familiar with R1. Three out of three staff stated R1 was using topical steroid cream on a daily basis for itch relief and could cause thinning of the skin when used often. Two out of three staff added in-service training was provided to care giver staff regarding the repositioning and transfers of R1 to minimize bruising and skin tears. One out of three staff added R1 was on blood thinners and that would have contributed to R1's bruising and instructed R1 to call for help when ambulating. On August 10, 2021, R1 had a fall with skin tears. Tears were treated. Home Health was requested and approved by physician. On January 4, 2022, R1 had a fall with skin tears. Tears were treated. Physician was notified and provided treatment plan. On March 5, 2022, R1 had a skin tear that was treated. Physician was notified and provided treatment plan. On March 10, 2022, R1 had a fall with skin tears. Tears were treated and physician and daughter were notified. On April 13, 2022, R1 had a fall with skin tears. Tears were treated. R1 was sent to the hospital for further evaluation due to hallucinations. R1 was discharged from the hospital and returned to the facility on April 18, 2022. R1 was placed into hospice on April 18, 2022 due to diagnosis of cerebral atherosclerosis. R1 passed on April 25, 2022. Therefore based on staff interview and records observed, the allegation of r esident sustained multiple wounds while in care is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of the report was left with the facility representative.