Complaint·October 23, 2025

Allegation "Staff handled resident in a rough manner:" The complaint alleges that on 09/28/2025, a female facility staff was observed handling R1 roughly when assisting R1 in standing up from their recliner. LPA interviewed residents and staff present during the time of the allegation. Staff denied the allegation. Residents interviewed stated the staff are always gentle with the residents and have never been observed to be rough. R1 could not recall an incident where they were handled roughly. Facility staff interviewed indicated that R1's family member would get upset with the staff when they would assist R1 in standing up, as R1's family member wanted R1 to transfer independently. Documents reviewed for R1 indicated R1 is a "fall risk." Staff interviewed were aware R1 was at risk of falling, and therefore would standby and assist R1 as needed when getting up from a seated position and when R1 ambulated around the facility. Although there are cameras in the facility, the cameras are only on a live feed and not recorded, therefore no footage was available for review. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Staff handled resident in a rough manner” is deemed UNSUBSTANTIATED at this time. Allegation "Staff did not report a change in condition:" The complaint alleges that R1 had a pressure injury and skin abnormality that was not reported to the family. LPA reviewed documents for R1 from the time of admission to the facility. Record review revealed that prior to moving into the facility, R1 had been in a Post Acute facility. Documents obtained for R1's care at the alternate facility indicated R1 had blanchable redness on their buttocks area. At the other facility, this area was to be cleaned and covered, but no additional treatment was ordered upon discharge. Facility staff interviewed indicated R1 had redness on their back and buttocks area as well as skin discoloration on their lower left leg upon admission to the facility, which is consistent with the documentation reviewed from the post acute facility. Staff indicated they did not observe any indication of pressure injuries and that while at times, particularly after showering, the skin would have increased redness, but this was consistent since R1 moved in. LPA interviewed additional parties who indicated R1's skin does still have redness. Administrator stated that since this redness was present when R1 moved in, they believed this was a chronic condition R1's family was already aware of. Based on the information obtained during the investigation, the Report Continued on LIC 9099-C Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Staff did not report a change in condition" is deemed UNSUBSTANTIATED at this time. Allegation "Staff did not seek timely medical care for a resident in care" It was alleged that staff did not seek medical treatment for R1's skin condition or pressure injury. Record review revealed that R1's skin had redness upon admission to the facility on 08/16/2025. Administrator indicated that prior to R1 moving into the facility, she had asked the family about R1's preferred medical provider in order to communicate regarding R1's medical needs. However, R1 did not have a primary care physician at that time. Interview with R1's current facility staff revealed that to date, R1 still does not have an identified medical care provider. The complaint alleges that when R1 was taken out of the facility for an outing on 09/29/2025, R1's family member noticed redness on R1's back and an open wound on R1's buttocks. LPA reviewed documents from a dermatologist who provided care to R1 on 10/01/2025. Documentation indicated R1 had two (2) stage I wounds to their buttocks and one (1) without any staging identified on their upper back. Photographs of R1's lower back/buttocks were reviewed during the investigation. Staff interviewed stated that the redness on R1's back and buttocks was present at the time R1 moved into the facility and at no time was a pressure injury observed, including during R1's shower the morning of 09/29/2025. It is unclear as to when the pressure injuries were sustained and whether this occurred while R1 was at the facility or out of the facility with their family. R1 could not recall a time their back hurt or if they had any injuries. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Staff did not seek timely medical care for a resident in care” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.