complaint·July 17, 2025

Review of R1’s hospice plan of care revealed R1 obtained hospice services on 03/12/25. R1 was unavailable for interviews during the course of investigation. Interview with the licensee revealed all staff were trained on daily skin care for R1 and only assisted with skin care which was ordered by the physician. Interview with the administrator confirmed that all staff received training on R1’s skin care which consisted of patting dry and applying a skin ointment. Record review of R1s hospice documents revealed their physician prescribed orders for Calmoseptine skin ointment and staff were instructed to ”apply a thin layer of Calmoseptine topical… daily and as needed…for skin care”. Interviews with S1 and S2 confirmed they followed physician orders for R1’s skin care and they attended the training provided by the hospice nurse. Based on interviews and record review, although the allegation is valid, there is not enough evidence to verify it is true. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation " Staff are doing finger pricks for resident " it was alleged staff checked the blood sugar level of R2 by pricking their finger. Interview with R2 did not reveal any pertinent information to the investigation. Interview with the licensee confirmed R2 used to do their own blood sugar level checks without staff assistance. Interview with the administrator confirmed R2 used to perform their blood sugar lever checks independently. R2 later acquired home health services to perform checks about once a week. Record review of R2’s home health orders revealed staff were to “assess compliance to regular finger stick blood sugar checks”, and the home health nurse was to assist with blood sugar checks. Record review of R2’s home health visit logs revealed that a home health nurse visited R2 about once a week since 08/01/24 to check R2’s vitals and blood sugar levels. Interview with S1 and S2 revealed they have never performed finger pricks on R2. No residents interviewed ever witnessed staff perform blood sugar checks on R2. Based on interviews and record review, R2 receives assistance form their home health care provider for blood sugar checks, and staff have not performed finger pricks. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation " Staff are not properly preparing food " it was alleged food was cooked and left out all day to spoil. During facility tours on 04/09/25 and today, LPA observed adequate supplies of perishable and non-perishable foods which were properly stored. All food was in good condition. Interview with the licensee and administrator noted food is always prepared and stored properly. Spoiled food is thrown out. Interviews with four (04) out of four (04) residents interviewed revealed the food is good quality and to their likings. Based on observations and interviews, the facility prepares food properly. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.