complaint·March 12, 2026

It is alleged that neglect / Lack of adequate care from staff resulted in resident sustaining multiple pressure injuries, specifically to feet, ankle, buttocks, hip and back. Record review revealed that resident (R1) had an order summary report at Town & Country SNF on May 24, 2022, with the following: rehab and evaluation for treatment are as follows, heel protector of heel, (TX) of coccyx, left groin, right groin, skin, bilateral heel, discoloration of bilateral lower extremities, and upper extremities as of 5/13/22. R1 was admitted to the facility on June 7, 2022. Functional capabilities assessment reflects reposition from side to side. Admissions records for Providence Home Health dated May 18, 2024, admissions diagnoses are pressure ulcer of left ankle stage 2, pressure ulcer of left heel unstageable, kidney disease, atrial fibrillation, thrombophilia, dysphagia, vascular disease, atherosclerosis of aorta, degenerative disease of nervous system, anxiety, and personal history of other diseases of circular system. Interviews with 2 of 2 staff stated that R1 had closed wounds and staff would apply ointment and/or bandages to them. Interviews conducted revealed that staff 2 of 2 stated that R1 did not have the wounds prior to entering the facility. Staff 4 of 4 stated that residents are rotated every two hours. Interview with residents stated that they are unaware of residents getting rotated because they don’t go into that resident’s room. Staff treat residents with dignity and respect. It is alleged that staff providing care beyond the scope of the license revealed the following. No dates or times were provided of when the alleged violation took place. It was reported that staff on duty provide wound care for R1’s pressure injuries sustained while under the supervision of the facility. Interviews with 4 of 4 staff did not corroborate the allegation. All staff stated that they provided sanitation of the wound if needed by applying ointment and bandages. R1 was admitted to home health and they provided wound care. Interview with resident stated that they have never witnessed any wound care treatment being performed on any resident. It is alleged that staff did not provide resident linens. It was reported that staff on duty denied a linen for R1 due to R1 getting the linens dirty too frequently. Interviews with 4 of 4 staff did not corroborate the allegation, it was stated that if a resident requires changing or cleaning, they provide that service right away. Interview with resident revealed the following, if clean linens are needed, they will receive them right away. Continued on LIC9099-C It is alleged that staff did not ensure that the residents’ toileting needs were met. It was stated that resident was observed to be soiled on several occasions, and they were changed only when it was brought to the staff’s attention. Interviews with 4 of 4 staff revealed that they change residents whenever it is observed that they have a soiled diaper. Interview with resident revealed that they have never witnessed any residents sitting in a soiled diaper. It is alleged that staff did not ensure resident was provided daily activities, specifically to staff leaving R1 in their room with no stimulation such as the television being on. Interviews with 4 of 4 staff revealed that the facility offers activities, however the residents do not like to take part in the activities. Interview with resident revealed the following that the facility does offer activities, however they do not like to participate in many activities. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.