complaint·July 22, 2025

Regarding: Staff do not seek timely medical care for resident. It is alleged facility staff did not seek medical attention in a timely manner for R1 on 7/16/25 when they were having trouble breathing and they asked staff to call 911 because they were turning blue. It is also alleged that 911 was finally called after 15 minutes in which they were eventually transported to the ER by ambulance. Furthermore, the allegation also states, staff have not helped resident look into getting a follow up on results for blood work taken seven months ago. The investigation revealed the following: Interviews with staff (1),(2) and (3) revealed, staff called 911 within (2) to (5) minutes of getting the call button alert from R1 in which R1 requested 911 to be called thorough the speaker. Three (3) staff stated, as soon as front desk staff (S4) called staff to answer to the 911 request from R1, (3) staff made their way to R1's room to check and provide assistance. S1 and S2 stated, R1 refused to get his vital signs checked, which is standard protocol when a resident is requesting emergency medical services; however, staff continued to attempt to get their vitals as 911 was being called. S1, S2 and S3 stated, ambulance arrived in less than (10) minutes and R1 was transported to the hospital. S4 stated, upon receiving the call button alert from R1 to the front desk, they immediately informed S3 to check in on R1 and S1 and S2 rushed to R1's room to assist. Seven (7) out of (8) resident interviews indicated, staff help with emergency medical calls in a timely manner. Seven (7) out of (8) residents also stated, they have no concerns with staff not providing care in a timely manner. Interview with R1 indicated, staff took too long to call 911 when they were having trouble breathing. Regarding staff not helping resident look into getting a follow up on results from blood work taken seven months ago, interviews with S1, S2 and S5 indicated, R1's referral to see specialist has been approved and now has an appointment which S2 helped resident in obtaining. Staff stated, R1 makes his own appointments; however, staff have offered to help him with scheduling appointments but R1 refuses. Interviews with (7) out of (8) residents indicate, staff are helpful with making their appointments for them if needed. Furthermore, (7) residents stated, staff are good at reminding residents about upcoming appointments Interview with R1 indicated, staff did not help with getting his blood work results; however, R1 now has an appointment to see the specialist. Staff and resident interviews do not corroborate the allegation. ***Continies on LIC 9099-C Regarding: Staff did not ensure resident’s medical equipment was maintained in operable condition. It is alleged that R1 had been asking staff to replace their breathing equipment which was damaged in a flood in their room and nothing had been done about it. The investigation revealed the following: Interviews with S1, S2, S3 an S5 indicated, R1 was provided with a loaner breathing machine immediately after the incident in which R1's breathing machine broke down. Interviews with (4) staff indicated, R1 manages their own breathing treatment medication by ordering it, picking it up from their pharmacy of preference and administrating the medication themselves. Four (4) staff stated, they will offer R1 to place orders for their medication if needed; however, R1 refuses to accept staff's help and manages their own breathing treatment and ordering their medication and supplies. R1's interview indicated, they were using the loaner breathing machine provided by facility staff after theirs broke down; however, R1 stated, staff should have helped them order a new one to replace the broken one. R1 stated, they don't like to go through staff when ordering their breathing treatment medication and supplies because facility pharmacy may take too long. Record review indicated, R1 is able to perform their own inhaler and nebulizer treatments, which also includes picking up their own prescription and supplies from their preferred pharmacy. Interviews with (7) out of (8) residents indicated, staff have not been neglectful to their medication and/or supply needs. Seven (7) residents stated, staff help with ordering medication and/or medication supplies in a timely manner when needed. Staff and resident interviews and record review, do not corroborate the allegation. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated .