complaint·July 9, 2025

Allegation: Resident was severely dehydrated due to neglect- Unsubstantiated Facility staff, including two (2) Licensed Vocation Nurses (LVN’s) who cared for Resident #1 (R1) all stated R1 was provided juice, milk and water with each meal. In addition, R1’s family provided them with a small refrigerator in their room that was stocked with water. There are also beverages offered in the dining room, bar and Bistro area all day and R1 was ambulatory and had access to these areas. Staff indicated that R1 could express their needs and would ask staff when they needed something. None of the staff ever observed any signs or symptoms of R1 being dehydrated. Medical Records for R1’s visit on 03/11/2023 states they were treated with IV fluids due to signs of clinical dehydration. However, it does not provide any other information. R1 had a second visit on 03/12/2023 and there was no documentation of dehydration. Allegation: Resident was severely malnutrition due to neglect- Unsubstantiated Facility staff, including two LVN’s who cared for R1 all stated R1 ate well. However, R1 would occasionally say they were full and not finish their meal because they did not like what was being served. None of the staff who cared for R1 observed any signs of R1 being malnourished. In addition, R1 was able to communicate their needs and ask staff for what they need. In February of 2023, staff voice concerns of R1 losing weight which was brought to the attention of R1s physician who prescribed R1 medication to enhance their appetite. R1 was sent back to the hospital on 03/12/2023, due to low blood pressure reading again. R1 was diagnosed with severe protein calorie malnutrition. However, there is a notation that states this condition was first noted on 03/18/2023, six days after R1’s admission to the hospital, and it is unknown if condition was present at admission on 03/12/2023. **Report continued on 9099-C** Allegation: Resident not changed timely- Unsubstantiated Interviews with staff indicated that caregivers are assigned residents at the beginning of their shift, which means they are to assist with those residents with incontinence care needs. Staff interviews further revealed that residents are assisted with incontinence care every two hours or as needed. Residents will also utilize their pendant if they need assistance between that time. Resident interviews revealed that staff meet their incontinence needs. Residents indicated they feel comfortable with staff and will use their pendants or staff will just check on them. Allegation: Due to neglect, Resident received a fracture while in care- Unsubstantiated According to facility staff, R1 had unwitnessed fall while at the facility. The first one in November 2022 and the second one in January 2023. R1 was evaluated by facility LVN on both occasions. R1 had no visible injuries, complaints of pain and when they were helped to their feet, they were able to walk without any complaints or signs of pain. Staff indicated that R1 was walking without assistances or signs of pain up until the day they were first transported the hospital on 03/11/2023. During R1’s visit to the hospital on 03/11/2023, record review indicated R1 had a Severe T8 Compression Fracture. Records reviewed did not contain any further details or how the fracture may have occurred or was treated. R1 had a follow up visit at the hospital on 04/04/2023. R1 was diagnosed with “Chronic appearing T8 Compression Fracture” Interview with medical professional revealed it is common for someone R1s age to suffer compression fractures and there is no way for them to determine the age of the injury or when it may have occurred. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided and appeal rights provided.