Complaint·April 8, 2025

R1’s ambulatory status declined, and R1 became increasingly bed bound. R1 was placed on hospice services on August 26th, 2022. The facility’s Needs and Services plan noted R1 required total assist. A Resident Assessment conducted on February 16th, 2023, revealed R1 required assistance with toileting and incontinence checks and changes. R1 required a two person assist for transfers, ambulating, and escorting. An external source revealed hospice visited R1, and trained caregivers on repositioning, wound care and keeping R1 clean and dry. This was documented on the Hospice care notes obtained from the facility. Interviewed caregivers and medication technicians stated they would reposition R1 every two hours, changed R1’s briefs, kept R1 dry, and would change out soiled bandages per hospice’s and nurses’ directions. These interviews noted hospice had not advised staff of any severe discrepancies in R1’s care, nor provided training. Although facility staff stated they kept R1 dry, repositioned R1, and that hospice did not communicate the severity of R1’s wounds, numerous notes from hospice noted R1 was found with soiled briefs and linens on multiple occasions. The hospice notes also revealed hospice communicated the importance of repositioning R1, and that hospice provided training for staff on multiple visits. Interviews with the facility’s Executive Director and Resident Care Coordinator confirmed the facility did not obtain a hospice care plan for R1, and instead followed the facility’s care plan for R1. The facility’s Need and Service Plan for R1 noted staff would follow orders within staff’s scope of practice. This plan did not note the need for repositioning. Interviews confirmed R1’s wound healing did not progress until after a care conference was held with facility management on February 23rd, 2023, and after the complaint was submitted to the Department. Based on the information provided during the investigation, the allegation was substantiated. It was alleged staff did not meet R1's incontinence needs. It was reported to the Department R1 was found to be soiled on multiple occasions. Hospice notes revealed hospice staff found R1 with soiled briefs and facility staff was trained and advised of the importance of keeping R1 dry. Interviewed staff reported providing R1 incontinence care and keeping R1 dry. Interviews with internal and external sources reported concerns with how long it took staff to respond to calls for assistance with incontinence care. (See additional LIC 9099-C for continuation of report.) Based on the evidence obtained, the allegation was substantiated. It was alleged staff did not provide clean linens to a resident. It was reported to the Department R1 was found with dirty linens on multiple occasions. Interviews with internal sources revealed the residents’ responsible parties and families were responsible for providing linens for each resident. Residents had a minimum of two linen sets, but some had more depending on their needs. During a visit to the facility, the LPA observed some of the residents’ linen supplies and the facility’s own linen supply. The facility had approximately six sets of sheets available, in the event a resident did not have a clean set. Although, the bedrooms observed had enough lines, there were several interviews that revealed there were occasions when linens were dirty and some residents had to wait for a set to be washed, or responsible parties were contacted to provide more lines. There were occasions when residents had to wait until the end of a shift for a clean set of linens to be placed on their bed. Based on the evidence obtained, the allegation was substantiated. These deficiencies were cited in an LIC 9099-D form and Plan of Corrections (POCs) were jointly formulated with Executive Director Wes Hebner. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report, LIC 811 Confidential names list, and Licensee Rights (LIC 9058), were provided.