complaint·December 17, 2025

During today’s visit, LPA Huynh, ED, and WD conducted a physical plant tour at 11:06AM. No immediate concerns were observed. The following was then determined: Allegation: “Staff did not prevent a resident in care from developing pressure injuries.” It was reported that Resident #1 (R1) sustained two (2) Stage II or Stage III pressure injuries on their buttocks, despite Staff repositioning R1 hourly. Interviews with five (5) staff indicated R1 experienced a rapid decline and was transitioning toward end of life. As a result, R1 was placed on hourly comfort checks. Staff were expected to reposition, provide incontinence care, and administer comfort medication as needed. Staff reported no observable changes in R1’s skin prior to 08/06/2025. Record review revealed R1 admitted to the facility on 01/05/2024 and was placed on Hospice care on 12/20/2024. R1’s hospice care plan reflected diagnoses of Chronic Obstructive Pulmonary Disease, Asthma, Hypertension, Anemia, Protein-Calorie Malnutrition, and was dependent on supplemental oxygen. Physician’s Report dated 10/08/2024 documented R1 as non-ambulatory, requiring full assistance with bathing, dressing, toileting, and transfers. The report also noted a history of skin redness to the buttocks with skin intact. Hospice records revealed that between 06/02/2025 and 06/17/2025, R1 had a Stage II pressure injury on their upper right buttock that required daily wound care which subsequently healed and did not require further care. On 07/22/2025, R1 reportedly had redness on their sacrum that staff treated with Calmoseptine ointment during incontinence care. On 07/30/2025, Hospice visit notes indicated R1 was unable to feed themselves and began to transition and was ordered to receive comfort measures. Between 08/02/2025 to 08/05/2025, R1 received daily visits from Hospice due to their imminent-death status and was reported to be non-responsive to verbal or tactile stimuli. Additionally, visit notes indicated R1 had a severe risk of developing pressure ulcers. Report Continued on LIC 9099-C On 08/06/2025 at approximately 1:30AM, staff reported that R1 had one (1) bleeding, open bed sore on the buttocks and one (1) skin irritation on the right shoulder that was accompanied by redness. The observations were reported to the Wellness Director and R1’s Hospice Agency. Calmoseptine ointment was ordered and applied per Hospice instructions after each incontinence change. Narrative Charting between 08/04/2025 to 08/07/2025, documented facility staff monitoring R1 every thirty (30) minutes to two (2) hours which included repositioning and incontinence care. Additional wound documentation was unavailable due to R1 passing on 08/07/2025. Based on interview and record review, R1 was bedbound, dependent on all activities of daily living, and experiencing rapid decline with multiple comorbidities, incontinence, and a documented history of skin breakdown. These factors placed R1 at high risk for pressure injuries despite preventative measures in place. Although R1 developed a pressure injury, there is not sufficient evidence to prove the alleged violation was a result of staff neglect, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.