complaint·April 24, 2025

On December 10, 2023, R1 was sent to the hospital due to an urgent health condition and did not return to the facility afterward. According to records, R1 remained at a skilled nursing facility until March 15, 2024. A Resident Move Out form dated April 24, 2024, confirmed R1 never returned to Sun City Gardens and officially moved out on May 2, 2024. Interviews with two staff members who provided care to R1 revealed R1 was non-ambulatory and R1 was able to stand up and walk. In addition, a Pre-placement appraisal dated June 7, 2023, indicated R1 required use of a walker and or wheelchair. Staff frequently reminded R1 to use a wheelchair due to R1’s tendency to move around without it, but neither staff member recalled R1 having pressure injuries during their time at the facility. Information obtained during this investigation did not corroborate the alleged allegation of R1 sustaining pressure injuries while in care. Based on record reviews and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.