complaint·July 17, 2025

R1 was seen at the hospital emergency room on March 24, 2025 due to abdominal pain. The medical records indicate that R1 was diagnosed with a UTI. R1 was discharged a few hours later and prescribed antibiotics. It was determined by the Department that the hospitalization was not for severe injury or great bodily harm. Additional hospital records from April 12, 2025 to April 16, 2025 were also reviewed by the Department. There were no indicators that additional hospital visits were due to staff neglect or due to staff failing to seek timely medical care. On April 12, 2025, R1 was seen at the Emergency Room due to a chief complaint of sepsis alert. R1 was admitted due to suspected pneumonia and physical deconditioning. R1 exhibited symptoms of confusion and shortness of breath, having experienced a week of cough and malaise, along with a day of altered consciousness. Tests revealed consistencies with R1’s baseline interstitial lung disease (ILD) and possible pneumonia. Computed Tomography (CT) scan showed findings of jejunal intussusception, but it was determined that no surgical intervention was necessary. On April 16, 2025, R1 returned to the Emergency Department with a complaint of abdominal pain and nausea. CT scan once again showed jejunal intussusception. Again, surgical intervention was not recommended. Push enteroscopy was performed on April 22, 2025. Procedure did not identify a clear cause for the intussusception. R1 was also treated again for UTI with antibiotics. CT scan on April 22, 2025 indicated that previously noted jejunal intussusception was no longer present. Unusual Incident/Injury Report (SIR) dated March 25, 2025 indicated that, on March 24, 2025, R1 was sent to the hospital due to nausea and back pain. R1 was treated with antibiotics for a UTI. SIR dated April 16, 2025 for R1 indicated that, on April 12, 2025, R1 complained of leg and arm pain. Facility offered to transfer R1 to be medically evaluated at the hospital. R1 informed paramedics that they were sustaining abdominal pain. R1 was treated for pneumonia and returned to the facility with new medication. SIR dated April 22, 2025 indicated that, on April 16, 2025, R1 told staff that they feel sick to their stomach. R1 was transferred to the hospital per request. SIR indicated that R1 was kept for more testing due to abnormalities found with CT scan. R1 did not return to the facility after hospital visit on April 16, 2025. ** Report continued on 9099-C ** R1’s Physician’s Report LIC 602A dated December 3, 2024 indicates R1’s primary diagnosis is major depressive disorder, recurrent and unspecified. R1’s secondary diagnosis is accidental poisoning by insulin and/or hypoglycemic. R1 does not have cognitive impairment and is able to communicate needs. R1 is identified as non-ambulatory. LPA reviewed R1's Centrally Stored Medication Form (CSMF) and observed R1 was prescribed a five (5) day supply of antibiotics on March 25, 2025. LPA did not observe any indication that medications were not given as needed. Interviews conducted with residents R2, R3, and R4 indicated that residents feel they are treated well by facility staff and they feel that their care needs are being met. 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 the report provided. Signature on these forms acknowledges receipt of these documents.