complaint·August 7, 2025

...Continued from Lic 9099-A Hospital discharge planners, doctors, home health nurses all suggested that R1 should be placed on hospice care due to his condition and requiring a higher level of care; and W1 was told by S1 and JMH home health nurses that the facility would not be able to retain R1 if his pressure injuries went beyond stage two per licensing regulations. On the allegation: Staff did not seek medical attention for residents in a timely manner. Based on interviews, on 3/15/24 R1 started having trouble breathing so W1 asked S3 to call 911. As the phone call was happening the phone was passed over to W1 at their request. On the allegation: Staff are not following residents’ special diet. Based on interviews, R1 was on a special diet of pureed foods and thickened liquids. R1’s physicians report and medical records state that R1 needed pureed foods that were honey thick, and R1 needed to sit up after meals at or above 45 degrees due to high risk for aspiration. Staff interviewed stated that they thought that W1 did not trust staff to feed him properly so W1 brought R1’s food to the facility to prepare it for him and fed him. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.