complaint·November 6, 2025

CONTINUE FROM LIC9099 Allegation: Due to lack of supervision, a resident physically assaulted another resident resulting in injury and hospitalization Investigation Finding: Unsubstantiated The Department interviewed R1, R2, S2, S1, S3, S4, and S5. Staff reported that during lunch service, R1 was heard screaming from R1s room, and that Staff immediately responded. S4 stated seeing R2 leaving R1s room, then found R1 on the floor with blood and what appeared to be defensive wounds. Per Staff, R1 reported that R2 was in her room and in her closet when R1 attempted to stop R2, whereby both had struck the other. R1 had fallen backwards. R2 was unable to provide information related to the event. Review of a police report responding to the incident showed that there was no determination as to whether an assault had taken place or if R1 had an unwitnessed fall. R1 was immediately transferred to hospital where it was found that R1 had sustained a fracture, a cut above the eyebrow, and bruising. Hospital records indicate that R1 also had a back injury. It was indeterminate when that injury took place and it was noted that it could have been associated with R1s overall condition. A review of R1’s file did not indicate that R1 was a fall risk, and there was no record to indicate a history of falling at the facility. There was also no information to suggest that R1 had displayed a history of aggression. The Needs and Services Plan and the Physician’s report had no information to indicate that R1 needed additional supervision. A review of R2’s file indicated a history of aggression towards staff, but had no information to indicate known aggression towards other residents. There was no indication of R2 needing additional supervision, or a 1:1 caregiver. All staff interviewed stated having no knowledge of R2 having a behavior of aggression towards other residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. CONTINUE FROM LIC 9099 Allegation: Resident In care was diagnosed with severe dehydration Investigation Finding: Unsubstantiated Interviews and record review (R1’s care notes) revealed that R1 was provided water, ensures, and juices. Charting shows that R1 was drinking the liquids that were provided to R1, however charting also revealed that R1 would on some occasions skip the ensure but would drink the water and juices provided. Interview with S1 revealed that R1 drank beverages on R1 own and was vocal about what drinks R1 wanted, and staff would provide and chart. Interview with S2 revealed that R1 loved coffee and would drink beverages on R1s own and that staff would measure intake. Interview with S3 revealed that R1 would drink beverages on R1s own and staff kept track of R1s intake. Interview with S4 revealed that R1 would drink beverages on R1s own and that staff would keep track on R1s intake. The Department obtained and reviewed R1s hospitalization report and there was no information to indicate that the resident had been dehydrated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated . CONTINUE FROM LIC9099 Allegation: Staff did not assist resident with feeding Investigation Finding: Unsubstantiated Interviews and record review revealed that R1 is able to feed self. Review of R1’s physician report shows that R1 is able to feed self. Interview with S1 revealed that R1 ate on own. Staff would prepare the food and bring it to R1 but staff never assisted with feeding. S1 stated that R1 also liked extra snacks and food and would eat on R1’s own. Interview with S2 revealed that R1 ate on R1s own and no one had to assist R1 with feeding. S2 also stated that staff would ask R1 if R1 wanted snacks and R1 would eat them all. Interview with S3 revealed that R1 would feed R1 self and staff would keep track of how much R1 ate and drank and that R1 ate normal portions and would give snacks and R1 would eat them and loves coffee. Interview with S4 revealed that R1 would eat all food in R1s room on R1’s own and that the facility provided R1 with water, ensure, coffee and tea and R1 would eat and drink normal portions. S4 stated that staff has never fed R1, R1 and without assistance. A review of the Needs & Services plan and the Physician’s report indicated that R1 is capable of feeding self. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegations are UNSUBSTANTIATED. No deficiency was cited during this visit. Exit interview conducted and a copy of this report provided.