complaint·January 5, 2026

Based on review of facility and home health care records and interviews with staff and witness, these allegations are determined to be unsubstantiated. Client #1 was admitted on 2/16/16 and was hospitalized on 9/14/23 for care and treatment of pressure injuries of buttocks, ankle and foot. Client was discharged from home health care on 9/7/23 because stage II pressure injuries of buttocks were responding well to wound care and healing. Stage I pressure injuries of ankle and foot were essentially closed and healed. Facility staff were provided detailed instructions for ongoing wound care by home health nurse on 9/7/23 upon home health discharge. Pressure injuries were observed and evaluated on 9/12/23 by home health nurse, necessitating resumption of home health nursing care for decubitus ulcers of ankle--stage III or IV--foot--stage I or unstageable--and buttocks--stage II. There was no evidence that the pressure wounds worsened because staff neglected to reposition client every 2 hours, nor that staff failed to change client's diapers and allow client to remain in soiled diapers for an extended period of time. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.