complaint·June 28, 2025

The investigation revealed the following: regarding the allegation “Staff did not seek medical attention for resident in a timely manner.” It is alleged facility staff did not seek medical attention in a timely manner for R1 on 03/20/2025. Staff interviews conducted by Community Care Licensing-Investigations Branch corroborated this allegation. Due to R1’s cognitive impairments, R1’s interview was unreliable. Interviews conducted revealed facility staff scheduled R1 to be transported via ambulance by First Rescue Ambulance service on 03/20/2025 at 2300 hour to seek medical attention for an injury that was not healing properly. On 03/21/2025, at 0630 hours, Administrator Hernandez arrived at the facility and was informed R1 was still at the facility and had not been transported for medical attention as scheduled. Staff waited 6 ½ hours before seeking medical attention for R1 after ambulance transportation service did not arrive at scheduled time. This poses immediate Health & Safety, or Persons Rights risk to persons in care. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. One (1) type A deficiency was cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email. The investigation revealed the following: regarding the allegation “Resident sustained a serious injury due to lack of care from staff.” It is alleged R1 sustained a serious injury on 03/10/2025. Staff interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Due to R1’s cognitive impairments, R1’s interview was unreliable. Records reviewed by Community Care Licensing-Investigations Branch did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiency was cited for this allegation. Exit interview was conducted. A copy of this report was provided via email.