complaint·November 6, 2025

(Continued from LIC9099) During the interview, staff indicated that multiple facsimile transmissions were sent to the medical organization responsible for managing Resident 1’s healthcare, informing them of the resident’s skin condition. The staff was awaiting direction from the medical team. Outside Source 1 (OS1) reported that pressure ulcers were identified during a routine visit. OS1 stated they had not been informed of any skin integrity concerns before the visit, nor had they received any documentation indicating that Resident 1 (R1) was experiencing skin issues.. Review of facility records revealed that a physician’s report dated February 26, 2024, documented that Resident 1 (R1) was non-ambulatory, diagnosed with dementia, and required total assistance with all activities of daily living. No family member or responsible party was listed. The first facsimile to R1’s health management team, describing the resident’s skin condition, was sent on May 28, 2024. Subsequent facsimiles were sent on May 29, June 3, June 5, and June 7, 2024. Facility records do not indicate any response received from the health management team regarding these communications. The facility policy states that if the facility is unable to care for a resident because of a change of condition the resident should be sent to the hospital for evaluation and treatment. There was no indication in R1’s care plans that the resident was receiving treatment for any skin-related conditions. Additionally, the care plans did not include interventions for repositioning while the resident was in bed or seated in a wheelchair to alleviate pressure and prevent further skin breakdown. The Department has investigated a complaint with the above allegation. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegations are substantiated. An exit interview was conducted with Ileana Castro, Assistant Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.