complaint·January 23, 2026

(Continued from IC9099, Page 1) Staff interviews revealed when R1 was originally admitted to the facility, they arrived with a rash and blisters. Staff confirmed that the rash eventually cleared up after a couple weeks with proper bathing and an unknown cream Contact 10 (C10) applied to R1's rash. According to staff, R1 was never evaluated by a medical expert for their skin conditions and staff admitted they treated R1’s blisters under the direction of C10 or on their own. One of the staff members said staff would gently put pressure on the blister to pop them and drain the fluid, so they would not get bigger. Staff stated that approximately one year ago, a larger blister developed in between R1’s buttock cheeks (coccyx). During conversations with Contact 1 (C1) and Contact 3 (C3), C3 stated they were concerned about the blister and asked C10 several times to have R1 evaluated by hospice or home health to get care for the blister. Facility staff made all responsible parties aware that staff were not qualified to care for the blister. None of the staff have any official training treating pressure injuries and the blister on R1’s coccyx was never evaluated by a medical expert. Records review revealed that On 8/31/2025, R1 was transported to the hospital to be evaluated for a possible UTI. Medical records indicated R1’s coccyx wound was first observed on 9/2/2025, sometime after 9:00 PM when R1 was given a bed bath. However, there is no documentation the wound was staged at that time. The wound was evaluated by a wound care specialist nurse the following morning 9/3/2025, at 7:30 AM and diagnosed as a stage three pressure injury. Outside Source interviews revealed that Contact 15 (C15) and Contact 6 (C6) agreed that R1’s coccyx pressure injury could have developed from what the Facility staff member observed on the morning of 8/31/2025 when changing R1’s diaper to a stage three pressure injury on 9/3/2025, at 7:30 AM, if it went unnoticed and untreated. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Licensee Jasna Popovich, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.