complaint·March 25, 2026

Continued from LIC9099 The caregiver then called for assistance from the night shift nurse as the caregiver saw R2 in R1’s bathroom. S1, S2, S3 informed LPA that protocol for a fall is for staff to call 911 for any unwitnessed fall. As the night shift nurse called 911 and assisted R1, the caregiver then tried to redirect R2 out of R1’s bathroom. R2 informed the caregiver that R2 was trying to find the bathroom and did not want to leave the bathroom due to R2’s urgent need. The caregiver was able to redirect R2 out of R1’s room and into a public bathroom nearby. Paramedics arrived, addressed R1’s skin tears, and took R1 to the Emergency Room. The paramedics also took R2 to the Emergency Room for evaluation. No Urinary Tract Infection noted for R2. R1 has a history of skin tears due to falls as noted in R1’s medical records and a history of Dementia. R1 Physician’s Report shows R1 has thin skin prone to tears. R1 does require assistance with toileting, wears diapers, but will still try to use the toilet on R1’s own. S1, S2, and S3 all informed LPA that R1 has a history of getting up at night to use the toilet and falling. R1 uses a wheelchair but will still try to walk on own thus causing R1 to fall. Staff have been monitoring R1’s sleep patterns to assist with toileting needs and encourage R1 to ask for assistance before getting up. R1 was brought back to the facility the next day with bandages covering the skin tears. No bruising or signs of physical abuse noted on the After Care Summary. LPA interviewed R1. R1 had no recollection of the incident. R1 did still have bandages on the skin tears. R1 could not recall why the bandages were there. R1 informed LPA R1 feels safe in the community. R2 moved into the facility two days prior to the incident. S2 noted the R2 had not slept the first full night, and very little the next. R2 was still very unfamiliar with the facility on the day of the incident. S3 did the initial move in assessment. S3 reported R2 showed no signs of aggression prior to moving in. S1, S2, and S3 all reported R2 being polite, easy going, and non confrontational with staff or fellow residents. After returning from the Emergency Room, S2, and S3 both suggested R2’s family hire a one-on-one care provider as R2 was still having difficulties sleeping and adjusting to new surroundings. LPA interviewed R2. R2 had family over who stayed in the room during the interview. R2 had no recollection of the incident. R2 reported still getting use to the facility, but enjoys it. LPA met R2’s one-on-one care provider, S4< who reported S3 being polite and respectful. Continued on LIC9099-C Continued from LIC9099-C LPA toured the memory care unit. LPA observed R1’s room is close to a common bathroom and to R2’s room. Residents in the memory care unit do not usually have their doors closed as confirmed by S2. It would therefore not be unreasonable for a resident with dementia and new to the facility to get confused and walk into the wrong room while looking for a bathroom. R1 did have an unwitnessed fall, and R2 happened to walk in at the same moment. LPA reviewed the staff schedule. There are two Resident Services Assistants and one nurse on night shift for memory care. All were working that morning. No resident before the day of the incident required a one-on-one care provider. LPA determined sufficient staffing needs were met on the day of the incident. Based on interviews and record review conducted, the above allegation is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy this report was provided.