complaint·February 28, 2026

Regarding the allegations: 1.) Staff neglect led to hospitalization of resident. 2.) Staff did not seek timely medical care for resident. It was alleged that Resident #1 (R1) was hospitalized for pneumonia, urinary tract infection (UTI) and dehydration due to staff neglect. The complainant also alleged that R1 was constantly dehydrated and that staff would not bring water to R1 unless R1 asked for it. Per record review, R1 was admitted to the facility’s memory care (MC) on 12/22/2021 and resided at the facility until 02/08/2025. Per an Unusual Incident/ Injury Report dated 01/28/2025, R1 was hospitalized on 01/26/2025, due to care staff hearing R1 making gurgling sounds and having a hard time swallowing food. LPA Peraldi subpoenaed R1’s medical records and conducted a file review. Per R1’s medical records, R1 was admitted to the hospital with the diagnosis of acute hypoxic respiratory failure, multifocal pneumonia and severe sepsis. R1 was eventually discharged back to the facility with hospice services on 02/04/2025 with the terminal diagnosis of cerebral atherosclerosis. A review of R1’s medical records and hospital progress notes revealed no indication or evidence of staff neglect or lack of timely medical care that would have led to R1’s medical conditions/ hospitalization. Per R1’s Social Service Documentation from a Medical Social Worker (MSW) dated 01/28/2025, R1’s Power of Attorney (POA) was made aware of the above allegations and R1’s POA did not have any current concerns regarding R1’s safety. Furthermore, the MSW educated R1’s POA on community resources available should there ever be a concern of R1’s safety or care. In addition, an interview conducted with Staff #1 (S1) revealed that care staff are trained to identify if a resident is not at their baseline and needs medical attention, which is why R1 was sent to the hospital. Based on information obtained during the investigation, there is insufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. 3.) Staff leaves resident in soiled diapers. It was alleged that staff do not change R1’s diapers or clothing. Per staff interviews, incontinence care is done every two (2) hours and before each shift leaves, staff do their last rounds and check on residents. The facility does not document progress notes of residents in their file. Resident interviewed did not reveal concerns regarding the above allegation. The information obtained during the investigation did not include sufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. Exit interview conducted with staff, Lily R. A copy of the report was issued.