K.P.
Jun 2026
After an unsafe experience at my mother’s first rehab, I chose this facility as her second rehab based on the positive reviews and because we wanted a fresh start. Initially, I felt hopeful. The environment seemed warmer, and I cannot deny that several nurses and staff members were kind, compassionate, and appeared to genuinely care about the residents.<br>However, our experience changed over the following week.<br>Because I work full-time, there were times I relied on phone updates, and I was repeatedly told that my mother was doing fine. During that time, I had already voiced concerns to the nurse practitioner because I noticed changes in my mother’s mental status beyond her baseline confusion. I requested additional evaluation, including laboratory work, because I wanted to rule out possible causes such as electrolyte abnormalities, thyroid issues, fluid retention, or another urinary tract infection. Given her multiple recent hospitalizations, I was trying to determine whether we were dealing with progression of dementia or ongoing delirium.<br>One evening on the weekend around 10 p.m., after finishing my shift, I stopped by unexpectedly and found my mother sitting at the nurses’ station shivering, appearing frightened, and unwilling to be alone in her room. The nurse caring for her was kind and attempting to comfort and distract her, and I appreciated her compassion, but I knew this behavior was not normal for my mother.<br>Earlier in the week, laboratory work had been ordered at my request. Since I had not heard anything regarding the results, I asked whether they had been reviewed. I learned that her BNP level had returned significantly elevated. My mother also had noticeable swelling in her legs and feet and had only received a one-time dose of Lasix. Despite these findings, I was told that based on her assessment she did not appear to be in congestive heart failure and that the plan was to continue monitoring.<br>While there, I personally checked my mother’s pulse and found her heart rate to be approximately 46 beats per minute. I expressed concern that it could drop even lower once she rested. I also voiced that her chills, confusion, fearfulness, and behavior were clearly different from her baseline.<br>The following day, while I was at work, I again received reassurance that my mother was “fine.” Shortly afterward, my sister contacted me and told me my mother urgently needed to speak with me. The moment I heard her voice, I knew something was wrong. She sounded frightened and unlike herself. I requested that she be sent to the emergency room. When there was a delay in receiving further instructions, I informed staff that if necessary, I would call 911 myself.<br>EMS ultimately transported her to the hospital and later informed me that her heart rate was 38 beats per minute. At the hospital, we learned she had severe hypomagnesemia with a magnesium level of 1.1, digoxin toxicity, and significant bradycardia. The BNP level obtained at the hospital differed from the outside laboratory result, but the emergency physicians agreed that she required immediate hospitalization.<br>I firmly believe that waiting until Monday could have had devastating consequences.<br>I attempted to address my concerns with administration because I was hoping for accountability and an opportunity to improve patient care. Unfortunately, I felt that responsibility was shifted elsewhere rather than acknowledging that my mother’s changing condition may have warranted closer assessment.<br>I sincerely appreciate the staff members who showed compassion toward my mother, and I recognize that other families may have had positive experiences here. However, this was our experience.<br>Today, my mother is at a different facility closer to family, where we continue to advocate for her care.<br>My advice to other families is simple: trust your instincts. No one knows your loved one better than you do. Ask questions, review Medicare ratings, and never be afraid to speak up when something doesn’t feel right. In our case, advocating for my mother may have prevented a tragic outcome.
