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32 | Based on document and record review, R1 was admitted to the facility on 09/20/2023. R1’s medical assessment dated 03/13/2025, stated that R1 exhibits aggressive behavior when getting out of bed. R1 is non-ambulatory due to both physical and cognitive conditions. R1’s individual care plan, dated 07/17/2025, specifies that during showers, R1’s wound should be cleaned with warm water, avoiding scrubbing, then gently patted dry. Staff are instructed to notify the medication technician (MT) or nurse to rewrap or redress R1’s foot. When transferring R1, staff must exercise caution with R1’s feet and ensure both legs are elevated every two hours. If R1 expresses discomfort, staff must notify the nurse or MT on duty immediately. R1 requires assistance from two staff members for transfers. Medical records indicate R1 is diagnosed with depression, dementia with behavioral disturbance, hypertension, and chronic osteoarthritis. On 08/24/25, R1 pulled a staff member’s hair during assistance with activities of daily living (ADLs). On 08/27/25, R1 exhibited a lack of appetite and was continuously monitored. On 08/28/25, at approximately 0800 hours, Care Staff (S5) informed S6 that R1 was observed with pink and white fluid on the left heel prior to showering. S6 photographed the heel, and notified R1’s responsible party (RP), primary care physician (PCP), and the facility’s former Medical Care Director (MCD).
On 08/29/25, R1 was evaluated at Stanford Health Care, accompanied by RP, and diagnosed with cellulitis of the lower leg, an open wound on the left heel, a Stage 1 pressure injury on the right heel, tinea pedis (athlete's foot) on both feet, and dementia with behavioral disturbance. The report noted that R1 has no appetite for four days and demonstrated increased aggressive behaviors, including agitation while seated in a wheelchair. On 09/05/25, RP initiated hospice admission for R1.
Based on record review and interview, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that resident sustained pressure injury due to neglect and lack of supervision and facility did not seek timely medical attention for resident's pressure injury are unsubstantiated.
No deficiencies were cited during today's visit. An exit interview was conducted with ED Karina Nevarez and a copy of the report was provided.
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