complaint·July 14, 2025

OA1 stated that the facility began "2 hour checks" on R1 and R2. OA1 stated that the facility staff are meeting the care needs for R1 and R2. OA1 stated that the facility calls them "right away" to report any new health or skin conditions for R1 and R2. OA1 stated that from what they have witnessed at the facility OA1 believes the facility had sufficient staff to meet the needs of the hospice residents. OA1 stated that when OA1 is in need of a caretaker OA1 notifies the front desk who then alert the staff and they always arrive quickly. LPA interviewed outside source (OS) who stated that they visit R2 regularly at the facility. OS stated that R2 has resided at the facility for over eight years. OS stated that facility staff often check on R2 but also allow OS to visit with minimal interruption. OS stated that R2 had a pressure sore on their foot which was being monitored by staff. OS stated that they are satisfied with the care that the staff are providing for R2. OS believed that the facility had sufficient staff to meet R2's care needs. LPA interviewed Staff 1 (S1) at the facility. S1 stated that they work directly with R1 and R2 and informed LPA that R3 passed away. S1 stated that they check both residents every two hours. S1 stated that due to the recent changes in management in the last few months their were some issues with communication between staff but now "it's all in place."S1 stated that the facility has an in-service training every month to address various topics including; catheters and hoyer lifts. S1 stated that when a hospice resident with an advanced stage wound is soiled the staff immediately advised hospice who then comes to the facility to clean the wound, change the dressing and change the soiled brief. S1 stated that although it is struggle at times with staffing due to "call outs" or resignations, they still manage to complete their tasks including; repositioning R1 and R2, checking if R1 and R2 are soiled and checking if R1's wound dressing is in tact. LPA interviewed Staff 2 (S2) at the facility. S2 stated that they believe the staff are meeting the care needs of R1 and R2. S2 stated that they immediately advise the med nurse when they see any issues with the hospice residents such as wound dressings that needs to be changed. S2 stated that although the requirement is that they check on R1 and R2 every 2 hours, S2 likes to check them every hour or hour and a half. S2 stated that during the check in's they reposition both residents and check if they are soiled or need their wound dressing changed. S2 stated that they believe their is sufficient staff to meet the needs of R1 and R2 as well as the other hospice residents. S2 stated that they usually get another staff member to cover the shift if someone "calls out." S2 stated in general their are two med-techs, four caregivers and one "floater" caregiver that work during the morning shift. LPA interviewed Staff 3 (S3) at the facility. S3 stated that although they do not work directly with the hospice residents they work along side the staff that do work with them. S3 stated that they believe the staff are providing proper care for R1, R2, R3 (before their passing) and all of the hospice residents. S3 stated that staff are required to check on R1 and R2 every two hours and they log their initials every time they do so. S3 stated that the facility has sufficient staff to meet the care needs of R1 and R2. S3 stated that although staff call out sick at times, they still manage to meet the needs of the residents in care. LPA interviewed Executive Director who stated that they fill staff assignments based on resident needs. ED stated that caregivers are assigned equally based on equity. ED stated that they make sure their is always coverage to meet the care needs of the residents. ED stated that if needed management step in to provide and fulfil resident care needs. ED further stated that at times the resident service director would assist with "med pass" to support the staff. Review of R1's service plan dated December 21, 2024 revealed staff were to provide R1 assistance every 2-3 hours for continence management. Service plan further revealed that R1 required assistance to turn and reposition in bed. Review of R2's service plan dated March 10, 2025 revealed staff were to provide R2 assistance with continence management every two hours during waking hours. Service plan further revealed that R2 required assistance to turn and reposition in bed. Review of R3's service plan dated March 10, 2025 revealed safety checks were to be completed during shift every 2-3 hours. LPA reviewed staff scheduling for the months of April and May 2025. On average the staffing for the AM shift included two medtechs and four to five caregivers. The PM shift included two med-techs and four to five caregivers. The NOC shift included one med tech and two caregivers. It should be noted that the facility staff oversee four floors in the facility. LPA also reviewed 29 staff time cards for the month of April 2025 and found that their was sufficient staff during each shift to meet the needs of the residents in care. LPA reviewed internal facility notes for R1 and R2 dated April 2025 and May 2025. Records review revealed the continence management task for R1 was originally set as every 8 hours but was modified to 2-3 hour checks effective April 15, 2025. Records review revealed on average R1 received continence management and repositioning every 2 hours from April 15, 2025 through May 20, 2025. Records review revealed on average R2 received continence management and repositioning every 2 hours from April 1 2025 through May 20, 2025. Records review revealed on average R3 received regular 2 hour check ins. R3's repositioning task began on May 1, 2025 and it was documented that R3 was repositioned every two hours. It should be noted that although one outside source was not pleased with the care that was given to R3, the majority of the evidence obtained including records review, outside source interviews, outside agency interviews and staff interviews all corroborated that the facility provided the care that was needed for the hospice residents and the staffing was sufficient. It should also be noted that the facility conducted multiple in service training's regarding charting of staff duties for residents from June 2025 through July 2025. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met. An exit interview was conducted with Nicole Long. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Nicole Long whose signature below verifies receipt of both.