Complaint Investigation Report

Hospice care plan and progress notes stated that the facility monitored R1 every two hours and repositioned R1 every hour. Hospice staff also visited 2–3 times a week. Facility staff would also check on R1 every 2 to 3 hours for incontinence care. During visits by hospice care staff, R1 was cleaned after a bowel movement. R1 was not left in soiled briefs when hospice care staff visited. 8 out of 8 staff stated that the facility staff checked on residents with incontinence care every 2 hours and that the residents who are bedridden are repositioned every hour. 3 out of 8 staff stated that any resident on hospice services has hospice care staff visit 2 to 3 times a week and has Hospice caregivers visit and sit with resident 2 to 3 times a week. GM stated that the staff followed R1s care plan and R1 was repositioned every hour and briefs changed every 2 to 3 hours.

1 out 8 staff stated that the R1s responsible party placed a white board in R1s room and wanted the date and time written when R1 was changed or when a caregiver entered the room and what services were done. S1 stated that Witness (W1) also took a lot of pictures and asked staff questions regarding policy and procedure. S7 stated that the facility was in constant communication with W1 about the care R1 was being provided. S7 stated W1 wanted to have more transparency regarding R1s care and have documentation provided when services were done.

S7 accommodated W1s request anytime he/she questioned R1s care that was being provided by staff and hospice services. W1 and POA of R1 had a meeting with Memory care director, hospice services and GM on 09/02/25 where R1s care was discussed and any concerns were addressed at that time. On August 18, 2025 Hospice notes states for facility staff to monitor R1s heels that showed redness.

On 10/10/25 LPA Yanez conducted another complaint investigation visit and interviewed 5 residents. LPA toured random rooms and observed beds with clean sheets and residents rooms to be clean.

LPA obtained Medication Technician training records which showed Medication Technicians are trained prior to dispensing medication. S5 stated the staff are trained on the computer and then will shadow the medication technician to get hands on training and are not left alone to dispense medication without competency exam.