complaint·April 13, 2026

The investigation revealed the following A llegation: Facility staff did not seek timely medical attention for resident. It was alleged that facility staff did not obtain urgent medical assistance for a resident after the resident experienced a fall and later reported feeling ill with numbness on one side of the body. It was further alleged that staff delayed contacting emergency services and instead arranged non-emergency transport several hours after the resident’s symptoms were reported. The resident was subsequently transported to a hospital, where diagnostic testing determined the resident had suffered a stroke On 03/11/2026 between the hours of 10:52am - 11:49am, the Department conducted an interview with the Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated the resident showed no signs of injury after the fall and initially denied pain. A1 reported that later in the morning the resident complained of soreness on the left side, and the Medtech on duty contacted non-emergency medical transport because the resident did not appear to be in immediate distress. A1 explained that staff made this decision rather than wait for the R1's family member who was called multiple times and did not answer to transport the resident, as staff had previously received pushback from the fire department for calling 911 for situations they considered non-emergencies. A1 stated that staff were instructed that moving forward, 911 should be contacted when a resident shows any concerning symptoms, and if the fire department has concerns, they are to contact the Administrator directly. A1 reported that staff assessed the resident, notified the resident power of attorney, and arranged transport consistent with their understanding of protocol at the time. On 03/11/2026 between the hours of 8:45am - 3:06pm, the Department conducted six (6) staff (S1–S6) interviews regarding the allegation. 4 of 6 staff denied the allegation. 2 of 6 staff were aware of the incident but did not confirm nor deny the allegation. Staff reported that the resident fell during the overnight shift, initially with resident denying pain, and appeared stable. Staff stated that the next day in the morning the resident reported left-side discomfort, and initial contacted non-emergency dispatch and Premier transport was contacted. Some staff reported attempts to contact the resident family member multiples times, while other staff stated that 911 was not called immediately after the fall because the resident initially felt no pain. Staff described following internal communication procedures and notifying supervisors. On 03/11/2026 between the hours 11:20am - 11:47am and 03/12/2026 between the hours of 10:45am - 11:10am, the department conducted 11 resident interviews. 11 of 11 residents denied the allegation. Residents generally reported that staff respond to their needs in a timely manner, feel safe in the facility, and did not report concerns about delays in medical care. One resident who experienced the incident stated staff assisted and medical help was obtained, though transport which took time. The residents had no knowledge of the incident or reported no issues with staff responsiveness. Report continues on LIC 9099-C On 04/10/2026, between 2:32 pm - 4:00pm, the Department conducted a record review and observed the following: on 03/01/2026 at 3:39 am, the facility’s wearable monitoring system detected a fall involving the resident. According to incident notes created on 03/03/2026, the resident reported falling while reaching for a remote and landing on their buttocks, which was also documented in a facility group text message at 5:53am on the same date. The notes further indicated that at 10:24 am, the resident reported difficulty moving the left side of their body, and non-emergency medical transport was contacted for evaluation. Staff documented multiple attempts to contact the resident’s responsible party at 5:36 am, 11:30 am, and 11:41 am, with voicemail inbox full, and a text message was sent notifying the responsible party that the resident was being transported for evaluation. Staff documented that the resident was assessed with no visible injuries such as bumps or bruising. Records also showed that the resident later complained of left-side pain at 1:45 p.m. and was transported to the hospital. A progress note dated 03/02/2026 at 1:57pm indicated that the hospital initially reported no stroke on CT scan, but an MRI later confirmed a stroke. Hospital records from 03/01/2026 - 03/05/2026 documented that the resident was admitted with left-sided weakness. A CT scan initially showed no acute findings. An MRI performed on 03/01/2026 revealed an “ acute/recent patchy infarct in the posterior right frontal lobe/precentral gyrus ,” confirming an acute ischemic stroke. The resident remained hospitalized through 03/05/2026 , receiving dual antiplatelet therapy, statin therapy, neurological monitoring, and rehabilitative services. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the 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. Exit interview conducted with Robert Jakini (Administrator) and a copy of this report was provided.