Complaint Investigation Report

Notes January 4 - January 29. 2026. Charting Notes report R1 is being fed and hydrated on January 4th and a change of condition occurred on January 14, 2026. Home Health was contacted regarding R1 having issues with swallowing. On January 16, 2026 the nurse assessed R1's swallowing and noted R1 was able to swallow water, as well as Ensure; a thicker liquid. The Responsible Party was notified by the nurse and continued to be updated of R1's changing condition. R1 was noted to be lethargic on January 20. 2026. Charting continued to document R1's food intake and hydration On January 25, 2026 R1 was lethargic and refused fluids or food. R1 was sent out to the hospital for further evaluation at 3;30pm. On January 26, 2026 home health recommended an R1 assessment for hospice but R1 was in the hospital at this time.

It was also alleged that Staff does not ensure to assist resident with feeding. LPA interviewed four of four staff members who all denied this allegation. Staff stated R1 was full assistance and was assisted with each meal in the dining room unless R1 refused. LPA interviewed three of three residents. Three of three residents denied the allegation that they are not assisted with getting food or water. LPA interviewed one witness who stated staff did not ensure resident was being fed or given proper hydration.

Based on LPA's record review, observations and interviews the allegations that Staff does not ensure resident is hydrated and Staff does not ensure to assist resident with feeding are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with Tony Reynolds, Executive Director and a copy of this report and LIC 811 were provided to the facility.