Complaint Investigation Report

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.