complaint·October 24, 2025

Upon admission a home health nurse was visiting once a week. Interviews with home health nurse of R1 revealed, on approximately 07/28/2025, they observed purple discoloration on R1's right ankle, which prompted the home health nurse to increase their visits to twice a week. On 08/05/2025, the care plan was modified. Due to R1’s inconsistent use of heel protectors, wound care was adjusted to include wrapping with gauze and to maintain dressing stability and support. Follow-up visits occurred two to three times a week for reassessment. Between 08/18 and 08/20, the dressing method was updated to include longer bandages overlapping the wound area for additional security. These remained in place most of the time but occasionally loosened when wet. By 08/25, there was no significant improvement noted. Non-adherence with heel protector use continued to impact healing progress. This concern was reported to a wound care specialist on 08/26. On 08/30, a wound care specialist visited R1 and observed the wound on the right ankle to be at a stage 2. Home health increased visits to 3 times a week and the wound care specialist visited once a week. As of today, wound care is ongoing with home health nurse conducting visits twice per week. The wound care specialist has discontinued in-person visits, as the wounds have improved and are now considered manageable under routine home health care. 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 violations did or did not occur, therefore the above allegation “Staff do not ensure resident’s medical needs are being met", is deemed Unsubstantiated at this time. It was reported that "Staff yell at resident" as it was alleged, that the Administrator Karina yelled at R1 over the phone. Interviews conducted with four (4) out of (6) residents in care revealed they have never observed any staff yell or speak inappropriately to any residents in care. Interviews further revealed that residents enjoy living at the facility and reported no concerns while living at the facility. Interviews conducted with (4) residents’ families/responsible parties indicated that none expressed concerns regarding communication with the Administrator. The Administrator denied ever yelling at any residents in care. 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 violations did or did not occur, therefore the above allegation “Staff yell at resident", is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.