Complaint Investigation Report

Witnesses 1 and 2 (W1 and W2) from the local emergency response agencies reported receiving calls from the facility that did not meet medical emergency criteria, including multiple calls per day during early January. One witness stated residents were left on the floor for responders to lift, and that these calls were categorized as public service rather than medical emergencies.

On 01/23/2026 at approximately 1:35 p.m., LPA Partoza received a phone call from Executive Director/Administrator (S1) regarding the above allegation. During the phone conversation LPA inquired if S1 is aware of the Provider Information Notification (PIN) 25-06-ASC. S1 stated that he/she is unaware of the PIN. LPA proceeded to read PIN 25-06-ASC to S1 and discussed the PIN with S1. LPA provided technical assistance to S1 with accessing the CCLD website PIN portal.

LPA interviewed the following staff (S1 to S8) on the following dates, 01/23/2026, 02/06/26, 02/27/2026 and 03/26/2026.

S1 to S8 stated that the facility is non-medical, has no 24/7 nurse, and does not maintain lift equipment. S1 to S8 stated, staff provide one person assistance and are not authorized or trained to take vital signs. Staff S1, S3 to S7 stated that staff calls 911 for unwitnessed falls, head strikes, new pain, and when residents were unable to bear weight or assist with transfers. Staff S1, S3 to S8 stated that 911 was contacted for lift assistance in non-injury situations due to size, weight or gender disparities between staff and residents and the absence of lift equipment. S1 to S8 stated that the facility does not have lift equipment and provides one person assistance.

On 02/27/2026, LPA Partoza interviewed four residents (R1–R4). R1 and R4 declined to be interviewed. R2 and R3 stated they required lift assistance in the past and could not be lifted by staff. R3 stated he/she began using personal lift equipment to avoid 911 calls.

Based on the documents reviewed, eleven 911 calls were made between 01/04/2026 and 01/31/2026. On 01/10/2026, two calls were made, one of the calls had no corresponding documentation. On 01/11/2026, two calls were made for two residents, followed by a third call on 01/12/2026 for one of the residents at the physician’s request.