complaint·August 8, 2025

Interviews revealed that R1 used a bell to alert staff that R1 needed assistance, however staff did not immediately respond to the bell, prompting R1 to ring the bell again and yell that they needed help. Staff 1 (S1) estimated that it was about a minute between R1’s first bell call and when S1 responded to R1’s room. Interviews revealed that S1 responded to R1’s room and made a comment stating that R1 was not the only resident requiring assistance and S1 could not immediately respond to R1’s calls. Interviews with staff revealed that two other staff were present at the facility who were not actively on shift during the incident. Interviews with staff revealed that once S1 observed that R1 was bleeding, S1 grabbed a towel to cover R1’s port to stop the bleeding and called 911. Interviews with S1 revealed that while S1 was on the phone with emergency services, one of the off-duty staff called the Administrator, which the Administrator confirmed during interviews. R1 was transported to the hospital via emergency services and returned to the facility on 4/29/2025. The Administrator stated that R1 was transported to the hospital within 15 minutes of S1 calling 911, however, other staff and residents were unable to provide a clear timeline of events between R1 beginning to bleed and when R1 was transported to the hospital. Interviews with staff and residents and medical discharge paperwork revealed that on 5/3/2025, R1’s port began bleeding again. Staff stated that S1 placed a towel on R1’s arm to stop the bleeding. Interviews with staff as well as review of S1’s personal cell phone call log revealed that S1 called 911 on 5/3/2025 at 9:43pm and the call lasted approximately 3 minutes. S1 stated that they stayed on the phone with 911 until emergency personnel arrived at the facility. Review of photographs provided to the Department by S1 revealed that emergency personnel were present at the facility at 9:57pm and medical paperwork revealed that R1 was admitted to the hospital at 10:38pm. Interviews did not provide the Department with a clear timeline of how long emergency services were present at the facility before transporting R1 to the hospital. Interviews with residents did not reveal concerns that staff were rude or spoke to residents inappropriately. Interviews with staff as well as review of progress notes revealed that R1 could be demanding and engaged in yelling and cursing behaviors. Staff also stated that R1 wanted assistance and requests for items or care answered immediately. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Administrator Teresita "Roxie" Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).