Complaint·April 2, 2026

transferred to the ICU for treatment. R1 was noted to have numerous preexisting health conditions including end state renal disease and dementia. R1’s condition did not improve at the hospital and was discharged back to the facility on September 10, 2025, on hospice. R1 passed away three days later. A copy of the death certificate reflects cause of death was end state renal disease. Interview witnessed stated that they visited R1 at the facility on a weekly basis and was happy with the care that was provided by caregivers had no concerns. Interview with 3 of 3 staff denied allegations of sepsis. Interview with 3 of 3 residents had no complaints regarding the level of care they received in the facility and denied any neglect or abuse by caregivers. It is alleged staff neglect resulting in injury to resident’s (R1) foot, specifically to having a hole. Record review from St. Joseph's Hospital R1 was admitted to the hospital on August 26, 2025, and was noted to have two small scabs on the heel of the left foot. Interview with R1’s primary caregiver at the facility denied seeing a hole on R1’s foot. Interview with witness stated they visited R1 on a weekly visit and denied seeing a hole on R1’s foot. It is alleged staff did not adequately turn resident, resulting in bedsores. Records review revealed that R1’s health was in decline due to existing medical conditions that included dementia and end stage renal disease. Upon admissions to the hospital on August 26, 2025, R1 had one pressure injury on their sacral area and scabs on left heel. While on the hospital stay R1 kept having skin breakdown issues and developed several additional pressure injuries. R1 was discharged from the hospital on September 10, 2025, and passed away three days later September 13, 2025, due to end stage renal disease. Information obtained from records reflects it appears that R1 health decline and pressure injuries were a result of R1’s actively passing and/or not from neglect or not adequately turning R1. It is alleged staff did not meet resident’s incontinence care needs. Record review revealed that R1 required diapers. Interview with 2 of 2 staff stated that R1 diaper was changed often, 6-8 times a day. Diaper was changed more often on the days when R1 had dialysis treatment. R1 had a bell as well to call for assistance when they needed it. Interview with 3 of 3 residents stated that their needs are met by care staff at all time and had no issues to report. Continued on LIC9099-C It is alleged staff did not assist resident with obtaining dialysis as needed. Interview with hospice staff stated that when R1 was admitted to the hospital on August 26, 2025, to September 10, 2025, attending physician determined that it would be beneficial for R1 to stop dialysis due to their current health condition. Interview with R1’s POA stated that when R1 was admitted at the hospital doctor advised POA that R1 should stop dialysis due to their current health condition and POA agreed that it would be the best course of action. Interview with 2 of 2 staff stated that when R1 came back from the hospital it was learned by hospice staff that R1 was no longer on dialysis due to their current health condition and decline. Based on the information mentioned above, the Department is unable to ascertain if all allegations mentioned above 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 violation occurred; therefore, this allegations are deemed Unsubstantiated. An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at facility.