Complaint·September 4, 2025

Staff stated R1 requires stand-by assistance with the shower. Multiple staff confirmed interacting with R1 in the days leading up to the discovery of the pressure injury and denied R1 had any changes in condition or signs to indicate a skin breakdown. Staff denied R1 verbalized any pain until 9/25/2024, the day R1 was sent out to the hospital. Moreover resident 1 (R1) reported that the pressure injury occurred at the hospital, not at the facility. R1 stated they did not believe the injury was present before hospitalization, as they felt no pain prior but began experiencing pain while lying in the hospital bed. R1 also mentioned they independently handle their own showers. An outside agency (OA) representative, during an interview, expressed no concerns about R1 developing a pressure injury at the facility. OA observed R1 using the toilet independently and managing personal hygiene. On 09/10/2024, OA noted that R1 was walking around, had intact skin, and vital signs were within normal limits. OA also assisted R1 with perineal care that day and observed no redness or signs of pressure injury. OA had no concerns regarding the adequacy of R1’s care at the facility. OA confirmed R1 was not receiving home health services for a pressure injury. OA assessed R1 prior to discharge from home health and did not observe an injury. Staff 1 (S1) acknowledged being present when R1 took a shower on 9/23/2024 as a stand-by assist to prevent R1 from falling. S1 asked R1 if R1 wanted help, but R1 refused and showered him/herself. S1 and multiple staff denied seeing a pressure injury at any time during care. R1’s records corroborated the staff’s statements that R1 was independent with care and ambulatory. R1 was on home health from 7/24/2024 to 9/10/2024. Based on the interviews conducted during the investigation and records reviewed the department was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.