complaint·April 10, 2025

On 07/23/2021, Home Health staff assessed the wounds as worsening and on 07/24/2021 R1, was sent to the hospital for wound care. Based on the evidence and interviews, there is no substantial confirmation that the unstageable wounds originated solely while R1 was under the facility's care. Allegation #2: Neglect/Lack of Care and Supervision The allegation indicates that R1, developed unstageable pressure wounds due to Neglect/Lack of care and supervision. R1 was diagnosed with an unstageable pressure wound on 07/24/2021. Interviews conducted and records review by Department staff revealed that on 07/07/2021, facility med tech staff (S1) notified R1’s PCP about a blister on R1’s left heel, after which staff provided routine care and bandaging. On 07/19/2021, R1’s Podiatrist noted heel ulcerations, which were free of eschar, and recommended Home Health services. On 07/20/2021, the facility administrator contacted R1’s PCP to request a referral for Home Health services. On 07/23/2021, and on 07/24/2021, a Home Health nurse assessed R1’s condition, noting the presence of eschar and classifying the wounds as unstageable. Interviews with a Certified Wound Specialist (S2) indicated that the initial description of the blister was consistent with a Stage II ulcer. The facility staff followed proper protocols, including timely notification of healthcare professionals when Home Health services were deemed necessary. Based on the information gathered, there is insufficient evidence to substantiate the allegations that R1 developed unstageable wounds or that neglect and lack of supervision occurred. The allegations are Unsubstantiated. A copy of this report was signed by LPA Prieto and Executive Director Patrick McAdoo-Morton . A copy of the report was provided to the administrator.