complaint·October 1, 2024

11/30, 12/4, and 12/8. All these documented dates stated that R1 had no verbal signs of pain such as grimacing or frowning. Additionally, R1 had a documented stage 1 wound on their coccyx which was identified and staged on 10/12/2023. Each subsequent visit described the wound and treatment. This wound was always described as a stage 1 with instructions to use barrier cream and cover with a bandage. There were no documented notes of this wound progressing or worsening. On 11/16/2023, R1 had a new skin tear to the right linear arm, close to the elbow. Treatment was stated for staff to cleanse with wound cleanser and pat dry. On 11/30/2023, R1’s right heal was noted to be red. Hospice provided foot protectors for staff to use to keep pressure off the heal. All staff interviews stated that R1 never had an open pressure ulcer. Staff described redness and were instructed to frequently reposition R1 in bed to alleviate pressure. LPA interviewed R1’s primary hospice nurse who stated that R1 never had an open pressure ulcer. This hospice nurse stated that, to their recollection, there was no odor. Additionally, the hospice nurse stated that if R1 had a stage 3 or stage 4 wound, nurse visits would have occurred several times per week for treatment. LPA did not identify a medical emergency for R1. R1 had a gradual decline. Notes show that hospice staff and facility staff communicated throughout R1’s decline. Allegation: Staff did not provide a comfortable temperature to resident. LPA learned that each room could control their own thermostat. Staff interviews did not reveal that R1’s room was kept unusually hot or cold. LPA interviewed R1’s hospice nurse who did not recall R1’s room being kept at an uncomfortable temperature. Allegation: Staff did not communicate with resident's authorized representative in a timely manner. LPA learned that there were several managers who were assisting the facility while they were seeking a Director of Nursing and Executive Director. Leticia Higares, a Regional Director with the company, was assisting the facility while R1 was actively transitioning. Leticia stated that she spoke with R1’s POA after learning that they had called the facility. Observation notes detail when med techs called R1’s POA. Per staff interviews and observation notes, R1 had a gradual decline. Observation notes also detail frequent communication between the facility and R1’s hospice company. Based on information obtained, LPA finds the allegations to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. A copy of this report was left with the facility.