complaint·August 28, 2024

S1 said they wanted to wait and see if the swelling will go down before sending to the hospital since vital signs were good. However, the following day, staff found R1 not as responsive when staff asked R1 for breakfast. S1 asked staff to check on vital signs and they were good but looked pale and weak so S1 instructed staff to call 911. Another staff member, S2 also mentioned that they have tried and elevated R1s leg but the following day R1 did have a change in condition as R1 looked pale and weak. S2 also shared that residents in the facility are always provided hydration every hour, even before going to bed. LPA tried to get in touch with RP but there was no response. Based on records review, facility sent an incident report indicating that they had called 911 for further checkup due to their observations of R1 being weak while being assisted getting up from bed, a swelling of left arm and an open wound on left elbow measuring about 3cm, swollen right leg and redness on buttocks and swollen ankle. Based on interviews & records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2