Complaint·December 16, 2025

During interviews with staff S1-S8, were asked when monitoring a resident how often they check on them, eight (8) out of eight (8) stated the resident is checked every hour when being monitored. During interviews with Residents R1-R8, were asked if staff assist them when they are not feeling well, eight (8) out of eight (8) stated yes, staff assist them and check on them when they are not feeling well. Additionally, Residents R1-R8 were asked if staff meet their needs, eight (8) out of eight (8) stated yes staff meet their needs. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today's visit LPA did not observe or cite any deficiencies. LPA conducted an exit interview with Maintenance Director, Pedro Gonzales, and a copy of this report was provided. Allegation: Staff did not seek medical attention for a resident. The allegation alleges that a resident’s blood pressure was high, and staff did not seek medical attention for the resident. During record review, LPA received and reviewed the R1’s Charting Notes and observed that when R1’s systolic is elevated over 180 paramedics have been called to assess the resident. LPA observed on 08/02/2025, 10/04/2025, and 10/07/2025 paramedics were called to assess R1 and provide transfer to the emergency room. During an interview with Staff S2 stated that when they checked on R1 a second time, before leaving for the day, R1 stated they were feeling a little better but wanted to rest a little while longer. During interviews with Staff S1-S8, were asked if resident’s receive medical attention in a timely manner, eight (8) out of eight (8) stated yes residents receive medical treatment in a timely manner. During interviews with Residents R1-R8, were asked if staff ensure they get medical attention if needed in a timely manner, eight (8) out of eight (8) stated yes, staff ensure they get medical attention when needed. Additionally, Resident R1-R8 were asked if there had been a time they did not get medical attention when needed, eight (8) out of eight (8) stated no, they have always received medical attention. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated Allegation: Staff did not reassess resident’s blood pressure in a timely manner. The allegation alleges that staff took a resident’s blood pressure and said they would be back in an hour to check on the resident and did not come back. During record review, LPA received and reviewed the Med Tech’s Shift Report for 10/12/2025 that states for the Notes (Day) “BP was high (159/60) [R1] said [they were] feeling flush. No fatigue, headache or pain. Elevated feet in supine position on the bed.” The shift notes for the Notes (PM) stated “BP was checked x2. First time was 141/64 second time was 154/60. Had resident elevate legs + rest + drink water.” During an interview with Staff S2, was asked how many times they checked on R1 when they reported they were not feeling well, S2 stated R1 informed them they were not feeling well at 1:50pm and they took R1’s blood pressure, assisted with elevating their legs and provided water. R1 stated they updated the next shift at crossover then went to check on R1 at 2:20pm before they got off shift.