complaint·October 15, 2025

Relevant party reported to the Department that resident (R1) allegedly sustained multiple pressure injuries due to staff neglect and was sent to the hospital regarding injuries on December 2, 2024. R1 was admitted to the facility on January 30, 2022, and had the following medical diagnoses: Diabetes Type 2, Hypertension, Atrial Fibrillation, Coronary Artery Disease, Chronic Kidney Disease, and Peripheral Vascular Disease. Per Physician’s Report (LIC 602A) dated March 8, 2024, R1’s ambulatory status was categorized as bedridden due to bilateral lower extremity weakness/paralysis unknown etiology. R1’s physical health status was marked as poor. R1 was noted to be incontinent of bowel and bladder function and required continuous bed care for potential skin breakdown. R1 was noted to be able to follow instructions and communicate their needs. R1 was noted to be unable to bathe and groom themself due to poor motor ability and weakness to bilateral lower extremities. Based on records reviewed, R1 had a history of refusing incontinence care and repositioning from time to time, including documentation by R1’s primary care physician. It was documented that refusal of incontinence care and repositioning increased after R1 was served a 30-day Notice to Terminate Tenancy due to a change in condition regarding R1’s ambulatory status on October 15, 2024. Care notes at the facility indicated that R1 was not compliant with their dietary restrictions. Care notes also indicated that R1 received an Alternating Pressure Pad/Pump mattress overlay to assist with skin breakdown and received Calmoseptine with change of briefs. Staff reported that R1 refused medication at times. Most of the care notes are regarding R1 refusing to reposition in bed or receive assistance with incontinence care. There were several notes regarding staff trying to convince R1 to go to the ER to have skin evaluated, including November 15, 2024, November 19, 2024, November 26, 2024, November 29, 2024, and November 30, 2024. R1 received assistance from Home Health starting November 21, 2024. Home Health included skilled nurse visits once a week and two (2) as needed visits. R1 had a wound assessment completed on November 21, 2024, indicating that R1 had two (2) Stage 1 wounds to their lower buttock. Treatment included cleaning and applying Calmoseptine. Home Health noted no changes to pressure injuries on November 26, 2024. ** Report continued on 9099-C ** Care notes for December 2, 2024 indicated that Administrator went to the facility to convince R1 to go to the hospital to have skin evaluated, in which R1 was agreeable. When paramedics arrived at the facility, R1 refused to go. Later that same day, staff reported R1 to have an altered mental status, including confusion. Staff contacted 9-1-1 and R1 was sent to the hospital. According to medical records, R1 was admitted at the hospital with chief complaint of altered mental status. Initial examination indicated R1 as somewhat altered and lethargic and unable to provide additional history. Initial lab test was unremarkable, with urine analysis positive for urinary tract infection (UTI). Other initial tests that were negative included CT of abdomen and pelvis with constipation without evidence of bowel obstruction, and CT of head without contrast and chronic senescent changes without definite acute intracranial process. Plan was for inpatient admission to medical floor for Acute Encephalopathy, or group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form. There are different types, each with different causes that range from infection, exposure to toxins, and underlying conditions. Condition was determined likely due to underlying UTI and groin fungal infection. IV antibiotics and fluids started, and urine and blood cultures were obtained to rule out systemic infection. Home medications resumed and anticipated stay was determined to be greater than a two (2) midnight stay. R1 was noted as full code. Wound Note evaluation dated December 4, 2025 indicated R1’s wound type as partial to full thickness, extensive denudation, most likely from moisture, possible deep tissue injury, with fungal component, present on admission. Recommendations were to apply Triad cream to buttocks, ischial, groin, perianal and sacrococcyx area twice daily and after every incontinence care, and antifungal cream to buttocks, groin, perianal and sacrococcyx area three (3) times a day. Pressure prevention included moisture control by managing incontinence promptly, strict turning every two (2) hours, off-loading buttocks and heels at all times, keeping the head of the bed as low as possible to reduce the risk of friction and shearing, using waffle cushion when in chair, nutrition consult and glucose control, and bedside nursing to manage dressing change/wound care. The treatment plan was effective, and wounds significantly improved. R1 stayed at hospital for over two (2) weeks due to complex placement issues. ** Report continued on 9099-C ** The clinical assessment of Home Health and Hospital visit indicated that R1’s pressure injuries are more of a fungal infection in nature. R1’s noncompliance with turning and repositioning and incontinence care contributed to them developing fungal infection. Review of R1’s medication noted that they were taking Jardiance 25 mg once a day. Jardiance is a SGLT 2 medication that treats type 2 diabetes by helping the kidneys remove sugar from the blood through the urine. This decreases blood sugar. It can also lower the risk of heart attack, stroke and heart failure. This medicine may cause vaginal yeast infections in women and yeast infections of the penis in men. This is more common in patients who have a history of genital yeast infections or in men who are not circumcised. This medicine may increase the risk of having urinary tract infections (e.g., pyelonephritis, urosepsis). Review of facility’s intervention for R1’s pressure sore was done in a timely manner by getting Home Health orders when they noted sore on resident’s buttocks and multiple occasions when they were trying to convince resident to have their pressure injuries evaluated in the ER. Based on records reviewed, the pressure injury cannot be attributed to negligent actions of the facility. During the investigation, LPA conducted interviews with residents R2, R3, R4, R5, and R6, as well as staff member S1 and Administrator, Susie Dizon. R2, R3, R4, R5, and R6 stated that they are treated well by facility staff and they feel that their care needs are being met at the facility. R2 and R4 stated that staff are good at providing care to the residents. S1 and Administrator stated that R1 refused care from facility staff, including repositioning in bed and incontinence care. S1 stated that R1 would also “fight" with their Home Health nurse who was trying to provide care to R1. S1 stated that R1 was resistive to care from everyone. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.