Complaint·October 7, 2025

LIC9099-C (Page 2) Allegation: Lack of care being provided Finding: Unsubstantiated On 10/28/24, Licensing Program Analyst (LPA) L. Hall interviewed Witness (W1). W1 stated that Resident 1 (R1) is receiving hospice services and had recently participated in a care conference with Staff 1 (S1). During the conference, S1 explained that the facility is working to establish a baseline for R1. W1 reported there has been no communication between the hospice agency and the facility. W1 stated that R1 told them he often waits 45–90 minutes for staff to respond to his call light. W1 was informed that the call system had been malfunctioning, which caused delays in staff response. R1 also reported that one weekend he was cleared to shower, and his wound dressing became wet. R1 was unsure who authorized the shower and who was responsible for changing the dressing. The following day, the wound area appeared red. W1 expressed uncertainty regarding what type of care the facility staff should be providing to R1. On 12/16/24, LPA Alexander interviewed W2, who stated that Suncrest Hospice provides services three times a week for wound care, bathing, and dressing R1. However, hospice staff also reported that they visit R1 daily to provide bed baths, and on days hospice does not come, facility caregivers provide R1 with a bed bath. W2 further confirmed that R1 cannot take showers due to wounds on his body. LPA interviewed S1 that stated that R1 was on hospice and that hospice staff provided R1 with a bed bath Monday through Friday, while facility caregivers provided bed baths on weekends. LPA interviewed Residents 2–6 (R2, R3, R4, R5, and R6), who stated that caregivers respond to their rooms and turn off the call lights. The issue regarding wait times for call light response had been substantiated in a prior complaint and was already addressed with the facility. LIC9099-C (Page 3) LPA L. Alexander reviewed R1’s physician’s reports, hospice care plan, and appraisal/needs and services plans. Based on record review and interviews, the evidence demonstrates that facility staff were aware of and providing the services required to meet R1’s care needs. Although concerns were reported regarding communication between the hospice agency and facility staff, response times to call lights, and wound care, there is insufficient evidence to prove or disprove that a lack of care occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.