Complaint Investigation Report

The investigation into the allegation, staff neglected resident resulting in severe dehydration and hospitalization, revealed the following. It was reported that R1 was hospitalized on August 27, 2025, due to dehydration and a urinary tract infection (UTI) and subsequently sent to a Skilled Nursing Facility (SNF) because the facility failed to ensure R1 was properly fed and hydrated. A review of records shows that R1 moved to the facility on July 9, 2015. R1’s physician report dated September 12, 2024, shows R1 has been diagnosed with Parkinson’s Disease, Epilepsy, Hypothyroidism and Hypertension. R1 is able to leave the facility unassisted and handle their own cash resources. R1 is not conserved, has no power of attorney and makes all their own decisions. On August 27, 2025, staff noted R1 to be lethargic. Staff assessed R1 and decided to call 911. R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025. Hospital records dated August 27, 2025, to September 5, 2025, show R1 could be argumentative to staff and refused medication on August 28, 2025. Hospital notes for September 2, 2025, state patient (R1) has not been eating well, refusing most meals, does take medication. Hospital discharge paperwork for R1 shows R1 did not have adequate intake of food and water but does not meet the criteria for moderate or severe malnutrition. The recommendation is for R1 to drink Ensure Plus High Protein daily with meals and the goal is to eat 70% of all of their meals and snacks. R1 was discharged to a Skilled Nursing Facility (SNF) on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. Based on the evidence gathered from interviews and a review of records, there is not enough evidence to prove that the staff failed to provide care or neglected R1, causing dehydration which resulted in hospitalization. Therefore, the allegation is deemed Unsubstantiated , meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.