During today’s visit, starting at 11:32 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations.

On the allegation Staff did not address a change in residents’ condition in a timely manner it is the concern of the reporting party (RP) that facility staff did not provide appropriate care to address the change in R1’s condition, which resulted in R1 being hospitalized. To investigate this complaint LPA conducted in person interviews, telephonic interviews, file and record review, corresponded via email and video chat, obtained copies of pertinent documents relevant to the investigation.

R1’s incident report revealed that on 10/03/2024, R1 was sent to the hospital at approximately 2:00 a.m. after the night nurse observed that R1 appeared pale. Vital signs were checked, revealing a present pulse and oxygen saturation at 71%. Oxygen was administered per physician’s orders, and 911 was called. CPR was initiated as directed by paramedics, and R1 was transported to Hospital #1 (H1).

Record review revealed that on 10/02/2024 facility staff communicated changes in R1’s condition to the PCP office via email and response time was between 5-7 hours.Report continued on LIC 9099-C PAGE 3...

The interview with the Administrator revealed that staff were monitoring R1’s residuals to assess digestion for their G-tube. Feedings were held three (3) times due to residuals exceeding 100cc. R1’s Primary Care Physician (PCP) was contacted after the first incident and advised staff to follow dietary orders. 10/03/2024 R1 was sent to the hospital at 2 a.m. after the night nurse noticed R1 appeared pale, pulse and O2 were checked. Pulse was present and O2 was at 71%. Oxygen was given per order and 911 was called. CPR was initiated as instructed by paramedics. R1 was transported to Hospital #1 (H1). R1 was admitted for respiratory failure. Intubation attempts were unsuccessful, and R1 experienced a gastrointestinal bleed. R1 was placed on high-flow oxygen. Additionally, the Administrator received only one (1) update from H1. Despite repeated calls, no further information was provided due to lack of authorization. As of 10/16/2024, no additional updates were received by H1. Prior to the hospitalization it was noted that RPR1 expressed concerns about R1’s body temperature and lethargy during visitation, though vitals were normal at the time and R1 was active with staff. On 10/23/2025 the Administrator was informed that R1 had passed away.

Interviews with staff revealed that R1 had one-to-one supervision and was constantly supervised. On 10/3/2024 around 2 a.m., R1 was sent to the hospital. Staff called 911 after observing symptoms. R1 was admitted in critical condition. R1’s assigned one-to-one staff provided support in the ICU and checked on R1 periodically. During the week of 10/3, staff noted R1 was not themselves. R1 did not eat, urinate, or have bowel movements on Monday 09/30 and Tuesday 10/1. R1 remained lethargic through Wednesday 10/2 and Thursday 10/3. Despite changes, R1’s vitals were normal and monitored closely by nursing staff. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not address a change in resident’s condition in a timely manner is deemed unsubstantiated at this time. No deficiencies were observed or cited during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.