Complaint·December 9, 2025

...Continued from 9099 and staff from St. Paul’s PACE provided nursing support to monitor her condition. According to S1, R1 disliked the colostomy bag and would occasionally pull on the tubing, causing leaks and soiling her clothing and bedding. R1 was no longer able to use the toilet independently and began wearing adult diapers (Depends) to prevent accidents. Shortly after R1 began using Depends, staff observed a rash developing around her vaginal area. During the interview, R1 did not report any concerns regarding staff or her own well-being. Facility staff and PACE nursing staff continued to monitor her condition. Based on the information available, there is insufficient evidence to conclude that the blisters or rash in R1’s vaginal area were the result of sexual abuse. On the allegation: Resident sustained unexplained injury while in care. Interviews and documentation indicate that the blisters observed on R1 were identified by facility staff and promptly reported to the PACE nursing team and W2. Following recent surgery, R1 returned to the facility with a new colostomy bag. According to S1, R1 often expressed discomfort with the colostomy bag and would occasionally pull on the tubing, causing leaks that contributed to skin irritation and the development of blisters. Facility staff and PACE nursing staff monitored R1’s condition. Based on the information obtained, there is insufficient evidence to conclude that R1’s injuries were the result of abuse or neglect. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.