complaint·March 26, 2026

OS1 stated they also contacted Hospice, who responded to the facility, assessed R1, and determined R1’s vital signs were stable with minor wound drainage. Hospice informed OS1 that an evaluation at a hospital would be reasonable. Based on this, OS1 requested non-emergency medical transport rather than 911 transport, and Hospice agreed. OS1 also requested that R1 be transported to a specific hospital where R1’s established specialists were located, which Hospice also confirmed was appropriate. It was also revealed that the Emergency transport (OSA1) from the original 911 call had arrived and provided OS1 that R1’s vital signs were normal, and the wound showed no active bleeding. OS1 also stated contacting the COO with this information and requested non-emergency transport. According to OS1, the COO agreed. It was revealed that then the Emergency transport (from the original call) discharged R1 while they were still at the facility. However, OS1 stated the facility contacted 911 again and R1 was transferred to an Emergency Room (ER). OS1 stated the COO later contacted them and informed them they did not have the authority to make requests for staff. The COO further stated that if OS1 continued calling, R1 would not be allowed to return to the facility, and they would be contacting the police. The COO then text messaged OS1 they were calling 911 and ended the call. OS1 reported sending text messages attempting to determine R1’s location after transport. The COO responded, “you are being told not to interfere.” Around 11:00 PM, a staff member texted OS1 and reported that the COO instructed staff not to allow R1 back into the facility unless staff contacted the COO first. OS1 attempted to reach the COO multiple times but did not receive a response. With no information provided by the facility, OS1 visited multiple emergency rooms that were able to provide OS1 R1’s location. OS1 found R1 in the ER, accompanied by the emergency transport, who also reported R1 was stable. OS1 disclosed R1’s wound dressing must have been changed at some point prior to their evaluation by the ER Physician, no bleeding or wound issues were observed, and pictures were secured and provided to the Department. At approximately 6:30 AM, hospital staff informed OS1 that R1 was ready for discharge and that facility staff confirmed they would readmit R1. R1 was transported by ambulance back to the facility, with OS1 following. Upon arrival, staff informed OS1 that the COO had directed them not to allow R1 back into the facility or their room. R1 and OS1 remained outside. OS1 contacted Hospice, who stated the facility could not refuse R1’s return. Hospice attempted to contact the COO. Staff attempted to connect with the COO by phone; however, OS1 overheard the COO decline to speak. Emergency medical personnel then spoke with the COO for several minutes. After this communication, EMT staff informed OS1 that R1 would need to return to the hospital. EMT personnel stated this decision was made by the COO and the facility owner and confirmed they were unable to compel the facility to accept R1. R1 was transported back to the hospital. During an interview, the COO stated that when R1 returned to the facility, staff communicated concerns regarding whether the facility could continue meeting R1’s care needs. The COO reported instructing staff not to readmit R1 until the COO had an opportunity to reassess whether R1 could remain safely at the facility. Because their reassessment had not yet been completed. An additional interview conducted with Outside Source 3 (OS3) disclosed they informed the COO that the facility could not refuse R1’s return and that Licensing would be contacted if R1 was denied readmission. OS3 reported advising the COO that a facility must readmit a resident after being released from a hospital or ER stay, unless a qualified professional has documented that the resident requires relocation or a higher level of care and the Department was notified, which had not been provided. While at the emergency room, OS1 received a call from R1’s Hospice agency indicating the facility reported that R1 required a higher level of care and could not return to the facility. OS3 also revealed speaking with Outside Source 4 (OS4) who corroborated the facility being in violation for not allowing R1 back into the facility/their room. [see LIC 811 for confidential name list]. Based on interviews, documentation reviewed, and corroborating statements, the allegation that the facility refused to re-admit R1 and failed to follow required procedures regarding resident acceptance, as well as violation of personal rights were determined to be substantiated. An exit interview was conducted with Jabul Gozales and a copy of the report and appeal rights were provided.