Complaint Investigation Report

Record review of R1’s emergency contact form from 11/18/23 and Medication Administration Record (MAR) from March 2025 indicated R1’s physician was Dr. Hove. Record review of an email from 06/05/24 from R1’s responsible person (F1) showed R1 had a new physician. Additionally, interview with F1 at 5:10 p.m. on 05/13/25 revealed they informed the facility that Dr. Padilla was R1’s physician around that time. Record review of incident reports from 03/03/25, 03/24/25, 03/25/25, and 03/27/25 indicated the facility notified R1’s family of the incidents but not their physician. Interview with the Care Coordinator (S1) at 11:25 a.m. on 06/04/25 revealed they did not contact R1’s physician after their falls in the month of March, though R1 was hospitalized after expressing pain on 03/25/25. S1 also noted that staff did not mention any reports of R1’s pain to them on 03/26/25 or 03/27/25. Interview with the Marketing Director (S2) at 11:05 a.m. on 06/24/25 revealed when families set appointments for residents, the facility typically reports resident conditions and status changes to family members so they can report to the physician. Interview with the administrator at 3:05 p.m. on 06/24/25 revealed the facility did not update R1’s physician of their changes per the family’s request. Also, the family frequently changed R1’s physician. Interview with Dr. Mulroy at 10:15 a.m. on 07/01/25 confirmed R1 had four (04) physicians within the past few years. Based on interviews and record review, despite R1’s changes of physicians, the administrator and staff did not report changes of condition to R1’s physician. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the corresponding LIC 9099-D page.

No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.