complaint·March 13, 2024

R1 was discharged from the hospital 08/15/2023 with physician’s orders to begin receiving hospice services. R1’s pressure injuries were initially healing and then progressed from stage two (02) to stage three (03) and four (04) under hospice care. During interviews with staff, all staff stated they have six (06) to eight (08) staff providing hands on care for about four (04) to six (06) residents per shift. All staff stated that R1 was checked on and rotated every two (02) hours or less, as instructed by the hospice agency. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.