Complaint Investigation Report

On 05/28/2025 and 08/05/2025, LPA interviewed three (3) staff members (ADM, S1, and S2) and R1’s POA.

R1’s POA stated that facility staff attended to R1’s needs very well, consistently monitored R1, and provided daily updates on R1’s condition. Medications were always administered on time. POA stated that they visit R1 at the facility 6 to 7 days a week. The ADM and staff provided the best possible care, and there was no neglect. R1 ate well, and a food assistant was available. R1’s POA expressed being very satisfied with the care provided, stating that R1 was receiving the best care possible for R1’s condition. R1 was not on total care and did not have ulcers, falls, or bruises.

R1’s POA stated that the RP was not helpful, refused to come on 05/20/2025 to evaluate R1, did not want to know R1’s symptoms, and offered the ER as the only option, and instructed staff to take R1 to the hospital. R1’s POA further stated that they decided not to allow RP to visit the facility on 05/21/2025 to see R1, as they have already changed the home health agency and expressed being very satisfied with the new agency, noting improved communication.

ADM stated that on 05/20/2025, staff showered R1, and R1 ate all meals, did not vomit, and did not have a fever. R1 appeared tired, confused, and was not walking around. Staff updated R1’s POA when the POA visited the facility that evening. The POA called RP and asked RP to visit the facility to evaluate R1; however, RP refused to come and instructed the POA to take R1 to the hospital. The POA and ADM decided not to call 911 since R1 was sleeping and instructed staff to observe R1 throughout the night and call 911 if there was an emergency.

The next day, the POA and ADM decided to have R1 transported to the hospital via ambulance for evaluation. While at the hospital, the POA requested a change of home health agency. When RP called ADM on 05/21/2025, ADM informed RP not to come to the facility as R1 was in the hospital and the POA had already requested a new home health agency.

ADM further stated that R1 was not on total care. R1 walked with a walker, received PT at the facility for exercises, could feed themself, and could get up from bed. R1 had not experienced any falls and never had bruises or injuries. Occasionally, R1 experienced episodes of hallucinations, and some medications caused R1 to feel tired.