Complaint·May 12, 2025

proper care at the facility. Record review revealed that R1 moved into the facility on 07/07/2023. At that time, R1’s service plan was at a level 0 care. Service plan indicated R1 was able to care for their own Activities of Daily Living (ADLs) and R1 was able to store and administer their own medications. Physician’s report dated 01/12/2024 indicated that R1 was admitted to hospice care, R1 “needs hands on assistance due to terminal decline” for ADLs including, but not limited to: bathing, dressing/grooming, toileting. At that time, R1 continued to store and administer their own medications. R1’s physician’s report indicates no history of skin condition or breakdown. ED stated that cost was a concern to R1’s family member and that R1 refused to allow an increase in care. ED communicated with both R1 and their family member, who began looking to move R1 to another facility. R1’s family member stated an outside provider would assist R1. Interview with facility staff revealed that R1 was very independent and R1 was able to care for their own ADL needs, even while receiving hospice care. Hospice assisted R1 with showers twice a week. Facility staff indicated that if a resident is bedridden or has a pressure sore, staff will assist with repositioning the resident every 2 (two) hours. However, staff stated that R1 was able to turn and reposition on their own and R1 was not bedridden until the last 2 (two) – 3 (three) weeks R1 resided at the facility. Staff interviewed did not recall R1 having any pressure injuries that they were made aware of. Hospice notes indicate R1 was regularly observed by their chosen hospice care provider, with regular visits in August and early September 2024. Notes reviewed leading up to R1’s hospitalization indicate “pts skin intact” on 09/03/2024. While hospice did document 2 (two) visits on 09/05/2024, documentation indicates R1 “declined further skin assessment, [R1] wanted to sleep.” Record review revealed that R1 did have a pressure injury on their left lower buttock noted “present upon admit” to the hospital. While records reviewed indicate R1 was admitted to the hospital on 09/05/2024 at 09:01PM, pressure injury was not assessed until 09/06/2024 at 12:45PM. Hospital records note “it appears this wound was bigger in the past,” however R1’s skin was noted to be intact during hospice assessment on 09/03/2024. It should also be noted that following R1’s hospitalization, R1’s family changed R1’s hospice provider. Plan of care and visit notes for the new provider do not indicate the presence of a pressure injury/wound. Facility staff interviewed were unaware of R1 ever having a pressure injury, and facility staff were not providing shower assistance or regular direct care to R1, so facility staff would not have been regularly observing R1’s skin for changes. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted and copy of report was provided.