complaint·July 29, 2025

Allegation: “Staff neglect resulted in a resident to be hospitalized” It was reported that Resident #1 (R1) was admitted to the hospital in regard to their blood pressure and it was alleged R1 received more than their usual dosage of blood pressure medication. R1 was admitted to the hospital on 07/13/2025 and was presented with generalized weakness, treated for hypovolemic shock, SVT aberrancy, elevated troponin due to NSTEMI Type 1 and 2, and acute renal failure. On the morning of 07/13/2025, R1 was administered six (6) medications, as R1 received everyday: Furosemide 40MG, Gabapentin 300MG, Multivitamin, Glipizide 5MG, Losartan Potassium 25MG, and Levofloxacin 500MG. In the late afternoon, R1 complained of hand numbness and the Licensee evaluated R1, notified hospice, and continued to monitor R1’s blood pressure. Staff #1 (S1) stated that R1’s Systolic blood pressure (SBP) and Diastolic blood pressure (DBP) was monitored every five minutes during which, R1’s reading continued to fluctuate as low as 90 and as high as 133. When R1’s SBP reached 170 and DBP 110, the Licensee administered Hydralazine 25MG, which was prescribed as a PRN (as needed) and instructed one tablet by mouth every 12 hours as needed for SBP greater than 160 and DBP greater than 100. R1 reported receiving a total of six (6) medications in the afternoon and could not recall what medications were administered. Resident #2 (R2) stated they did not observe R1 receive any medication during this time. After the Hydralazine was given, the Licensee and S1 continued to monitor R1’s blood pressure when it was observed to drop significantly and Hospice advised the Licensee to give R1 a glass of water with salt. R1’s blood pressure rose back up in the higher range and the Licensee proceeded to notify hospice that they would call emergency services. Paramedics arrived, evaluated R1, and advised R1 to go to the hospital and R1 refused to go to the hospital. Report Continued on LIC 9099-C R2 reported R1 was very difficult with their care needs and commonly refused services provided by the facility staff, physical therapists, and hospice nurses. Hospital nurses were on the phone with R1 via the paramedics, and R2 convinced R1 to go to the hospital. R2 stated that throughout the incident, hospice nurses were on the phone with the Licensee, and they did everything they could to address R1’s health issues. At the end of the day, the Licensee called emergency services to further assist R1. 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 deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.