Complaint Investigation Report

Allegation: Staff failed to provide necessary hydration, nutrition and basic care

During investigation, LPA interviewed reporting party (RP), staff (ADM, S1) and reviewed R1’s documents. Resident (R1) had a fall from her home and was first admitted at the facility on 07/19/25. During her stay at the facility, R1 was evaluated by her primary care physician who recommended hospice services be provided since R1 would not eat because she did not like the taste of medications given. R1 was admitted into hospice care on 08/26/25. Staff (ADM, S1) stated they followed the hospice care plan for R1 which was to provide a special diet (R1 has Type 2 diabetes), hydrate and continue to administer medications, document refusal of medications and work with hospice care team in assisting R1 improve her condition. On 11/21/25, hospice care team determined R1's health has improved to the point that hospice care is no longer required. Review of R1’s hospice discharge summary report dated 11/22/25 showed R1 had improved mid-arm circumference. Hospice discharge report also showed R1’s initial intake of meals were 30%, upon discharge her daily consumption of meals were 25 to 75%, eating 3 meals a day. occasionally eating 100%. Her independent functioning has improved from 1: 1 feeding on admission to being able to feed herself on discharge and that R1 had a stage 2 pressure injury on admission but was healed at the time of discharge. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff failed to provide necessary hydration, nutrition and basic care to R1 is unsubstantiated.