complaint·May 12, 2025

Resident developed a pressure injury due to staff not repositioning resident. – Unsubstantiated The Department received and reviewed R1’s medical records. The medical records indicated there were not pressure injuries present on R1. Throughout interviews with staff and medical record reviews, it was determined R1 had irritation and redness on the coccyx area. The facility provided documentation acknowledging that R1 primary stayed in bed or a wheelchair and would need to be repositioned frequently. With repositioning’s often and application of cream to the area, the facility and hospice were aware of the affected areas. Based on the investigation, observations and interviews conducted the allegation is UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Facility staff left resident in soiled clothing for an extended period of time. – Unsubstantiated The complaint alleges facility staff did not address R1 being left in soiled clothing in a timely manner. Based on interviews that were conducted, LPA could not prove or disprove that the allegation occurred. LPA received consistent statements, that residents are checked every 2 hours throughout the day and night. LPA reviewed the Service Plan which indicated that the resident needed assistance with toileting and dressing. LPA could not corroborate the allegation. Based on the investigation, observations and interviews conducted the allegation is UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.