complaint·December 29, 2025

Regarding the allegation: Staff did not provide medical attention to resident in a timely manner. It was alleged that staff failed to seek medical attention for R1 resulting in R1 being admitted to the hospital on 12/12/2025. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with S2 revealed on 12/11/2025, R1 was observed to have discoloration of their tongue and when they notified the Medication Technician (Med Tech), they were told that R1’s newly prescribed medication can cause such discoloration to occur. S2 then stated that on 12/12/2025, R1 was observed to have elevated concerns due to their diagnosis prompting staff to seek medical attention for R1. S2 stated that all of this was documented in the staff communication charts for review. LPA’s interview with S1 revealed that prior to R1’s medical incident of 12/12/2025, R1 had an unwitnessed falls on both 12/03/2025 and 12/04/2025. S1 stated when they tried sending R1 to the hospital due to them noticing they had increased weakness and refusal to eat, R1 denied medical attention. LPA’s interview with R1 revealed that they know when they need to go to the hospital or when they do not need to go. LPA observed R1’s interview to be contradicting for they would say that they didn’t remember the facility calling 911 but then would later state otherwise, “…I think maybe they did”. When questioned if they signed paperwork showcasing their refusal for medical assistance, R1 confirmed. LPA’s record review of the facilities’ communication chart (Connect Team) confirmed that facility staff did document the health-related issues pertaining to R1 in between the dates of (12/03/2025 to 12/12/2025), where it was notated R1 refused medical attention from emergency services on 12/03/2025, 12/04/2025 and 12/06/2025. Further record review of R1’s discharge paperwork from the hospital revealed that R1 was prescribed medication which when researched online confirmed said medication can cause discoloration of the tongue. Additional record review of the facility’s Unusual Incident/Injury Report (SIRs) confirmed the facility had self-reported to Community Care Licensing Division (CCLD), R1’s medical incidents where they refused treatment. LPA confirmed R1’s refusal of treatment per the facility’s, “Resident Acknowledgment of Refused Care” dated: 12/03/2025, 12/04/2025 and 12/06/2025. Further record review of R1’s Medication Administration Record (MARS) along with R1’s daily medical log confirmed, staff were conducting daily monitoring of R1’s medical levels specifically on 12/11/2025. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Wellness Director.