complaint·November 6, 2025

The investigation revealed the following: Allegation: Facility failed to seek timely medical attention to the resident It was alleged that the facility failed to seek timely medical attention for Resident 1 (R1), who was believed to be sleeping throughout the morning of September 27, 2025, but was later found unresponsive around 12:40 p.m. and was transported to the hospital. On 10/13/2025, between the hours of 1:12pm - 1:23pm, LPA interviewed Administrator (A1) regarding the allegation. A1 was unaware of the allegation and stated he doesn't recall anything at all in regard to the resident's condition nor what steps were taken when staff realized the resident was unresponsive on the morning of 09/27/2025 at approximately 8am. A1 did not have a response when asked at what point did staff notice that the resident was unresponsive or show signs of distress. A1 stated the facility process for checking on residents consist of standard practice every 2 hours for residents. If resident is asleep, the staff won't wake up the resident for dignity and will do otherwise if necessary for physical/medical needs for food and or medication. A1 stated the staff makes the determination to contact emergency services or for medical help. On 10/13/2025, between the hours of 9:04am - 11:30am, LPA interviewed 7 staff in regard to the allegation. 1 of 7 staff confirmed the allegation and stated a Medtech informed Staff 7 (S7) and a previous LVN who no longer work at the facility were informed that Resident 1 (R1) wasn't looking well. S7 and former LVN observed R1 unresponsive and contacted 911 who then came to the facility to take R1 to the hospital. 3 of 7 staff were aware of the allegation due to being informed by other staff since these staff were off from work on the day of the incident occurring. 3 of 7 staff were unaware of the allegation by not have any knowledge of the incident due to not being scheduled to work that day. On 10/20/2025, between the hours of 8:30am - 10:00am, LPA interviewed 10 residents regarding the allegation. 2 of 10 residents confirmed the allegation and stated that staff do not take action, respond slowly, and provide poor assistance to those in need of medical attention. 6 of 10 residents denied the allegation and stated not having to wait a long time before receiving help when sick. 2 of 10 residents were unaware of the allegation stated not knowing and or never witnessing it due to keeping to themselves. LPA unable to interview Resident 1 (R1) as resident passed away while at the hospital on 09/30/2025. On 11/05/2025, between the hours of 9:35am - 9:45am, LPA conducted a records review and observed the following: LIC 602 Physician Report for Residential Care Facilities for the Elderly (RCFE) - dated on 09/10/2025 states that R1 had dementia and his primary diagnosis was coronary artery and secondary diagnosis(es) was congestive heart failure. LIC 603 Preplacement Appraisal Information stated R1's health history of 3 back surgeries and a heart stent. Furthermore, staff informed the Medtech and former LVN that R1 appeared to look unwell which has resulted in R1 being unresponsive. The facility immediately contacted emergency first responders who arrived at the facility to transport R1 to the hospital. Upon R1 being transported to the hospital, the resident was alive. Report continues on LIC 9099-C Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. 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. Allegation: Staff did not communicate with resident's representative in a timely manner. It was alleged that staff failed to communicate with the resident’s representative in a timely manner regarding the resident’s condition and subsequent hospitalization, and that the facility administrator did not respond to the representative’s multiple attempts to discuss the incident. On 10/13/2025, between the hours of 1:12pm - 1:23pm, LPA interviewed Administrator (A1) regarding the allegation. A1 did not confirm nor deny the allegation and stated A1 stated that the Medtech or licensed nurse is typically responsible for informing the resident’s family when there is a medical emergency or major change in condition. A1 further stated that management or staff did not follow up with the family after the incident, as it is the family’s responsibility to communicate with the hospital once the resident is transferred, and the hospital is responsible for providing updates to the family. On 10/13/2025, between the hours of 9:04am - 11:30am, LPA interviewed 7 staff regarding the allegation. 5 of 7 staff denied the allegation and stated that when it's a change in the residents’ condition the family is notified immediately.1 of 7 staff were unaware of the allegation and stated not knowing if family is notified of the resident's change in condition. 1 of 7 staff did not confirm nor deny the allegation but stated staff told the nurse and Medtech first who will then contact the family. On 10/20/2025, between the hours of 8:30am - 10:00am, LPA interviewed 10 residents regarding the allegation. 1 of 10 residents confirmed the allegation and stated the facility doesn't tell their family right away when something happens with their health. 7 of 10 residents denied the allegation and stated their family have not and did not find out late about something that has happened to them such as not feeling well or going to the doctor and or hospital while being here at the facility. 1 of 10 residents didn't confirm nor deny the allegation and stated that their family doesn't care. 1 of 10 residents was unsure of the allegation and stated not knowing if the facility contacts their family later or after the fact if and when something has happened such as not feeling well or going to the doctor and or hospital. LPA unable to interview Resident 1 (R1) as resident passed away while at the hospital on 09/30/2025. On 11/05/2025 between the hours of 8:25am - 8:45am, LPA conducted a records review and observed the following: Upon the incident occurring, an initial report was made to the resident's responsible representative by the facility in regard to the incident that occurred with R1. However, the facility did not communicate after the incident occurred with R1's responsible party. Report continues on LIC 9099-C Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. 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 deficiencies were cited for the allegations above. An exit interview was conducted, and a copy of this report was provided to Joel Niblett (Administrator).