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32 | Per R1’s certificate of death, the listed causes of death are asystole, severe decubitus sacral ulcers, severe protein calorie malnutrition, and stroke with residential left sided weakness. Per R1’s Physician’s Report dated May 9, 2025, R1’s diagnosis included Cerebrovascular accident with left sided hemiparalysis, Hypertension, Atrial fibrillation, Dyslipidemia, and Mitral valve insufficiency. It also states that R1 required continuous bed care, had a history of skin breakdown, and was bedridden. There was also no indication that R1 had any open wounds at this time. Per R1’s Preplacement Appraisal Information, Reappraisal, and Appraisal/Needs and Services Plan dated May 17, 2025, it described R1 as needing full assistance with activities of daily living (ADLs), such as transferring, bathing, toileting, and with medication. The records also do not indicate that R1 had any open wounds upon their admission to the facility.
A review of the wound care progress notes for R1 revealed the following information: On January 28, 2026, R1 was observed to have a stage four pressure ulcer on their left buttocks and a stage four pressure ulcer on their sacrum. It also states that care giving staff were advised to reposition R1 every two hours. On February 4, 2026, R1 was observed to have a third wound to their left hip which was also diagnosed as a stage four pressure ulcer. It also indicates that the wounds to R1’s left buttocks and sacrum did not improve and remained at stage four pressure ulcers. On February 12, 2026, R1’s wound to their left hip did not improve and remained at a stage four pressure ulcer. R1’s wound to their left buttocks was diagnosed as a stage three pressure ulcer. R1’s wound to their sacrum was not evaluated during this visit. Despite R1 having a change of condition due to the pressure ulcers, there is no documented evidence that the facility updated the care plan for R1 to address this area. There is no documented evidence that described how the facility would be assisting R1 with their pressure ulcers. Additionally, there is also no documented evidence that the facility staff repositioned R1 every two hours as instructed by the wound care specialist.
A review of internal communications from the facility revealed the following information: Staff #3 (S3) reported observing two areas of redness on R1’s tailbone area on December 2, 2025. S3 reported their observations to the facility Administrator, Staff #1 (S1), but did not specify to S1 the name of the resident that they were referring to. S3 provided wound care treatment to R1 between the dates of December 2, to December 24, 2025, including putting patches and ointment on the red areas of R1. It should be noted that S3 does not have any formal education or training on wound care. S3 is also not a licensed medical professional that is able to provide wound care treatment. S3 also acknowledged that the redness to R1’s tailbone area did not improve during these dates and that the wounds only worsened in condition. S1 reported that they only became aware of wounds that R1 had on January 21, 2026. CONTINUED ON LIC9099-C
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