Complaint·May 4, 2026

It was learned that R1 had a tendency to contact 911 since R1 had a personal cell phone which R1 kept on his/her person. It was learned that most of these calls were made when R1 felt a surge of pain or felt anxious about any physical concerns. It was learned that R1 sought out 911 for medical attention but would refuse to go to the emergency room once the paramedics arrived to transport R1 to the local hospital. Based on a review of the forms and documents gathered during the course of this investigation, it was noted that R1 was sent out to the local hospital for a total of (2) times only from the start of August 2025 until December of 2025. It was learned that R1 returned the same day back to this facility. On one hospital visit dated on back in October 2025, R1 returned back to this facility without any new orders or changes made to R1's medical or physical care requirements. On another hospital visit after 911 was called, R1 returned back to this facility on the same day in December 2025 with a new prescription due to loose stool and diarrhea. There weren't any new changes or additional physical care needs addressed or warranted at that time. Based on interviews conducted during the course of this investigation, it was learned that R1 was often times confused and anxious about the pain that R1 was experiencing with R1's knees. It was learned that this led R1 to act out in frustration due to the chronic pain that R1 was suffering from and R1 would often times take it out on R1's spouse and facility staff when they attempted to intervene. It was learned that R1's care plan was completed upon admission to this facility to address these issues which the facility staff were made aware and were trained on how to de-escalate and redirect when R1 got into these bouts of frustration and lashing out. It was learned that R1 did not have any contracted services for care through a home health agency, hospice, or wound care at this time. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview