Complaint Investigation Report

9099C-1.. Allegation Staff are not caring for resident's wounds. The allegation states (R1) has open sores all over their body from head to toe that are actively bleeding and staff are not cleaning them and resident has not had a diagnosis for over a year.

On 3/25/25, LPA observed (R1) resting in bed and to have an extensive "rash" on their arms, legs, bottom of the feet and ears. The Director of Nursing (DON) was also present and showed LPA the bottom of resident’s foot that had blisters, explaining the skin condition starts out as blisters but then turns into a rash that is bleeding. (R1) stated she has gone to their health care provider emergency room at least 15 times to treat the rash, indicating they are "trying not to itch, but it still itches and burns". (R1) confirmed they have "nerve damage”, “staff puts on all lotion". and the “lotion helps”. (R1) stated the "rash" started with cyst on the back.

On 3/25/25, the DON stated resident (R1) was at the hospital for (9) hours yesterday due to blisters and has a dermatology appointment on June 2, 2025. The DON confirmed that the hospital ER did not do a skin scrape to test for scabies. The DON confirmed she can only minimally help (R1) with on-line scheduling on her phone and that (R1) has an auto immune condition that could be contributing to the rash.

Hospital documentation shows (R1) went to the emergency room on 3/24/25 and was prescribed two new prescriptions: Clobetasol(Temovate) 0.05 % ointment to be applied to the affected area two times daily for two weeks; and Doxycycline Monohydrate (Avidoxy) 100 mg – 1 tablet to be taken two times daily for 14 days. The hospital discharge paperwork also notes that a follow up dermatology appointment was scheduled on 6/2/25.

A person that knows (R1) stated that the client can’t seem to get an accurate diagnosis as to what the sores are as she has been told they were scabies, but that stated that no one has scabies for over a year.

LPA reviewed hospital documentation showing (R1) visited the emergency room on 3/17/25 for the skin rash and was prescribed a new prescription for Hydro-Cortisone (Hytone) 1% top cream to apply to affected area(s) one to four times daily and given information on rash care. No future appointments were noted on the discharge paperwork.