Complaint Investigation Report

LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 08/01/2025) , , LIC 621 Resident Personal Property & Valuables (dated 12/20/2024) LIC 613 Personal Rights (dated 12/20/2024) Resident Assessment (dated 12/31/2025), Service Plan (dated 07/29/2025), Medication Administration Record (January - March 2026), Communication Logs (dated 03/01/2026 & 03/03/2025. Alert Report for Care Predict (03/01/2026), Staff Schedule (dated 02/22/2026 - 03/07/2026) and Notice of Employee as to Change in Relationship (03/05/2026).

The investigation revealed the following:

Allegation: 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.