complaint·December 16, 2022

There was an allegation that staff did not address resident’s change in condition. Record review revealed an admission date of 06/23/2022. Care notes indicate that resident was sent out on 06/24/2022 for a change of condition and that family was notified. Per interview with Health Services Director, R1 steadily declined while in care which resulted in hospice admission on 07/02/2022. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. There was an allegation that neglect/lack of care and supervision resulted in resident sustaining an unstageable pressure injury. R1 was sent to hospital on 06/24/2022 for change of condition. Hospital performed skin assessment and noted no pressure injuries. Skin assessment performed by hospice on 07/03/2022 indicated skin abrasion on coccyx but not an unstageable pressure injury. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies cited during today's inspection. Exit interview conducted with Teresa Weerts and a copy of this report emailed to the facility.