complaint·April 22, 2026

Additional information obtained from staff members indicated that there were no concerns brought to their attention regarding the use of the pressure mattress. When interviewed, R1 stated there were no concerns since their arrival to the facility and that they have only been receiving services from Home Health for a few weeks. R1 advised that they had just recently arrived at the facility a few months ago, and that this was the first time the nurse had ever come to the facility to dress or change the bandages. There were no stated concerns or challenges with how the facility staff attended to meeting their daily needs. Information obtained from interviews with additional residents indicated there were no concerns or challenges with how the facility staff attend to their daily needs. LPA made several attempts to contact and interview additional relevant Witness to no avail. LPAs review of the records, including a sampling of the residents files, verified there were no other residents receiving care from home health for pressure injuries at the time of this investigation. Based on information obtained from interviews, record review and observations, the evidence received pertaining to the allegation Staff did not ensure resident's pressure injury was covered with dressing, has been deemed unsubstantiated. An unsubstantiated allegation means although the allegation may have happened or is valid, there is not a preponderance of evidence to demonstrate the alleged violation did or did not occur. An exit interview was conducted. A copy of this report was discussed and given to the Facility Manager, Elena Leon.