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32 | Review of R1’s medical records revealed that on October 13, 2025, R1 had an emergency room visit due to inflammation of their wound. Review of facility records revealed that the Executive Director of the facility self-reported R1’s emergency room visit to the Department. Per record review and interviews, R1 was on home health services for wound care and on October 13, 2025, R1 was receiving wound care from the home health nurse when R1 had complaints of pain. R1 was then sent out to the hospital via emergency services. Records review and internal and external source interviews did not reveal that neglect/lack of supervision resulted in R1’s hospitalization, as R1 was on home health services for wound care and R1 returned back to the facility from the emergency department on the same day.
Review of R1’s medical records revealed that R1 was home health services for wound care and outside source interviews confirmed that R1 was being seen by a home health nurse three times a week for wound care. Review of R1’s home health notes revealed that R1 was seen by the home health nurse on October 16, 2025. Outside source interviews and records review did not reveal that R1 was scheduled for wound care on October 15, 2025. Also, interviews with internal and external sources did not reveal that R1 was confined to their bedroom nor did the facility staff take away R1’s wheelchair.
Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that neglect/lack of supervision resulted in resident’s hospitalization, licensee did not ensure resident received wound care, facility staff are not allowing resident to use wheelchair, and facility staff are not allowing resident to leave bedroom. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Karen Roper and Assistant Executive Director Theresa Gamez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
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