Complaint Investigation Report

Allegation: Staff failed to observe change in resident’s condition

During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. Staff (ADM, S1) confirmed with LPA that on 06/23/25 S1 spoke with ADM on the phone around 11AM who requested him to check on R1. S1 stated he checked on R1 and did not notice any change in condition. ADM also spoke with R1 on the phone and told POA that he sounded fine. POA stated she called R1 again and observed R1 have slurred speech and that his face was drooping. She immediately called 911 so that he can be taken to the hospital right away. R1 was taken to the hospital by paramedics and diagnosed with a stroke and urinary tract infection. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff failed to observe change in resident’s condition was found to be substantiated.

Allegation: Staff failed to meet resident’s medical needs in a timely manner

During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 06/23/25 while on a Facetime call, POA observed R1 have slurred speech and that his face was drooping. POA immediately called ADM to have staff check on R1. ADM stated that staff checked on R1 around 11:15AM and that he sounded “fine”. POA stated staff did not call 911. R1 called POA again and requested for 911 because staff was not doing anything. R1 was picked up by paramedics on 06/23/25 and was admitted at the hospital with a diagnosis of a stroke and UTI. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff failed to meet resident’s medical need in a timely manner was found to be substantiated.