Complaint·August 15, 2025

R8 passed away while receiving hospice care in April 2025 at the facility. LPA conducted review of progress notes documenting routine hospice visits for comfort and wound care. LPA’s review of R8’s hospice records and care plan revealed R8 required assistance with all activities of daily living (ADLs) including repositioning. According to hospice records, facility staff received training on March 3, 2025, for pressure injury management from the hospice agency, including guidance on proper reposition techniques, importance of maintaining strict reposition intervals, and incontinent care routines. Interviews conducted with the Administrator and three (3) staff members assigned to R8 revealed that staff followed hospice-provided instructions regarding wound care, repositioning procedures/routines, and incontinent care. LPA’s review of the hospice agency wound care records indicated R8’s wound was improving. R8 had received routine care from the facility staff, in addition the facility staff confirmed they followed the facility’s procedures such as, routine room checks and repositioning, as well as those from the hospice agency. Based on record review and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.