complaint·September 24, 2025

***CONTINUE FROM 9099*** Resident interviews were also consistent, with R3 stating, “the staff are very nice and take good care of us,” while R4 shared, “I don’t have problems with the staff.” LPA’s observation during the tour showed staff engaged in scheduled care responsibilities. Review of staff schedule, resident files, including charting notes and individualized service plans, indicated that care delivery and monitoring were consistent with residents’ needs. No documentation supported that staff behavior created a risk or led to lapses in care. Allegation: Staff did not prevent a resident from assaulting another resident - Unsubstantiated W1 reported that “two incidents occurred where R1 was hospitalized after being assaulted by another resident,” and stated "staff failed to intervene". Staff interviews confirmed an altercation occurred between residents; however, S1 stated, “both responsible parties were notified right away and both residents were sent for medical assessment.” S2 similarly reported that staff “reacted quickly and ensured the facility protocols are being followed.” A review of R1’s file, including charting notes, and incident reports and LPA's interview with S1, revealed that R1 was taken to Urgent care by the responsible party at W1's request ,and follow-up steps were documented. S3 stated " I notified the nurse immediately when the altercation happened we made calls and left voicemail". Based on staff statements and file reviews, staff responded and documented the incident as required. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff left a resident outside in extreme heat for an extended period of time- Unsubstantiated W1 stated that “a resident was left outside in extreme heat for over an hour” and found by her daughter showing signs of overheating. Interviews with S3 and S4 did not confirm this incident, and both stated they “are attentive when residents are outdoors, especially in hot weather.” LPA interviewed R3 who stated, “I usually see one or two staff outside checking in if a resident is outside".Review of daily charting notes and assessments for residents did not show any documentation of a resident experiencing heat related issues. During the tour, LPA observed shaded areas in the outdoor space. Allegation: Staff does not communicate effectively - Unsubstantiated W1 reported that “communication was hindered as the caregiver did not speak English” during an incident. Interviews with S1–S4 revealed that some staff speak English as a second language, but all were able to effectively communicate with residents and facility leadership. S4 stated, “I can explain care needs in English, and if needed, I ask another staff to help.” R3 confirmed, “the staff understand what I want,” while R4 shared, “I never had problems talking to them.” Additionally, during the visit, LPA was able to communicate directly with all staff and confirm they understood questions and responded to questions asked. A review of resident service plans and charting notes showed that care instructions were being followed. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff did not properly report incidents involving the residents - Unsubstantiated W1 stated there “should be unusual incident reports on file” regarding the resident altercations. A review of R1’s and R2’s files revealed that incident report was sent to CCL and a copy of the incident report was reviewed by LPA. Documentation also showed charting notes for both residents aligned with the reported timelines and follow-up care. This agency has investigated the above allegations. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.