complaint·August 27, 2025

LPA interviews with resident’s primary care physician, hospice nurse, and resident’s family member revealed R1 was not diagnosed with pressure injuries at the time of this allegation and the unexplained injuries were likely bruises caused by previous falls R1 had sustained at the facility. Based on the information obtained, the allegations are deemed unsubstantiated at this time. On the allegation: Resident's toileting needs are not being met. It was alleged that on 3/30/2025 and 3/31/2025 facility staff did not change R1 all day and in the evening both days Person 1 (P1) assisted R1 clean up and get ready for bed. Interviews revealed P1 was brought on service by R1’s family to provide R1 additional support. Interviews revealed R1 did have a rash where the briefs sit on the resident’s body that may have been caused by not being assisted with their continence needs timely. 6 of 6 staff interviews reveal R1 has occasional accidents, R1 often asks staff for assistance to the restroom, and staff are not aware of R1 having a rash due to not meeting R1’s continence needs. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies cited at this time. Exit interview conducted, report signed, and report provided to the Administrator.