complaint·December 4, 2025

Allegation: Staff did not properly transfer resident resulting in resident sustaining a fracture Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & R1’s responsible party (POA) and reviewed resident (R1) documents. Staff stated that R1 requires assistance with all activities of daily living and that a Hoyer lift is required to move R1 from the bed to her wheelchair. Review of R1’s documents showed no previous falls were documented or reported. On 05/26/25, R1 had an unwitnessed fall in her bedroom at approximately 0530 hours. Staff evaluated R1 and no injuries or complaints of pain were noted at the time of her being found. R1 went about her day as normal. Around 1000 hours, R1 complained of pain to staff who sent her to the hospital. Review of R1’s medical records showed R1 was admitted to the hospital on 05/26/25 and discharged on 06/01/25. R1 was diagnosed with a “right distal femur fracture.” R1 stated that she did not remember how she got on the floor. R1 noted that her bed had bed rails and believed she must have just “rolled off the bed”. Staff stated they did not know how R1 ended up on the floor in her room at 0530 hours on 05/26/25. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not properly transfer resident resulting in resident sustaining a fracture is unsubstantiated. Allegation: Staff punched resident Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Review of police report dated 06/15/25 showed S3 denied punching R1. During visit, police officer checked R1’s stomach and did not see any bruising or marks. Residents (R1, R2, R3) denied any abuse (physical or verbal) from staff. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, abuse or mistreat any resident at the facility Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff punched resident in care is unsubstantiated. Continued on next page, LIC-9099 C pg2 Allegation: Staff handles resident in a rough manner Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Residents (R1, R2, R3) denied any abuse (physical or verbal) from staff. Staff (ADM, S1, S2, S3, S4) denied handling R1 or any other resident in a rough manner. ADM stated she has never seen any staff hurt a resident. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, abuse or mistreat any resident at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff handles resident in a rough manner is unsubstantiated. Allegation: Staff does not treat resident with dignity and respect Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Residents (R1, R2, R3) denied any abuse (verbal or physical) from staff. Staff (ADM, S1, S2, S3, S4) denied being rude to any resident in care. ADM stated she has never seen any staff rude to any resident. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, verbally abuse or mistreat any resident at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff does not treat resident with dignity and respect is unsubstantiated. Allegation: Facility is not providing assistance with receiving incidental medical care Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & and reviewed resident (R1) documents. Review of R1’ s admission agreement showed she was first admitted at the facility on 02/15/23. Staff stated that R1 requires assistance with all activities of daily living and that a Hoyer lift is required to move R1 from the bed to her wheelchair. Residents (R1, R2, R3) stated staff assist them with their activities of daily living such as personal hygiene, toileting, incontinence care, doctors’ appointments, medication administration, pharmacy refills and that they have no issues with staff failing to meet their needs. On 05/26/25, R1 had an un-witnessed fall and staff sent R1 to the hospital for evaluation and treatment the same day. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility is not providing assistance with receiving incidental medical care is unsubstantiated. Continued on next page, LIC-9099 pg 3 Allegation: Staff are not adequately trained Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4), reviewed resident (R1) documents and staff training records. Review of R1’ s admission agreement showed she was first admitted at the facility on 02/15/23. Staff stated they assisted R1 with her special diet, incontinence care, transfers from bed to wheelchair using the Hoyer lift, bathing, dressing, toileting, medication administration and meals. ADM stated she is a licensed registered nurse and has trained staff on how to properly use the Hoyer lift. Residents (R1, R2, R3) stated they like living at the facility and had no issues with staff failing to meet their needs. Review of staff 2025 training records showed they completed the required 20 hours of annual training for dementia care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not adequately trained is unsubstantiated. Allegation: Facility does not follow reporting requirements Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) and reviewed resident (R1) documents. Review of incident report regarding R1’s hospitalization on 05/26/25 showed facility submitted the completed self-report to CCLD on 05/30/25. ADM stated they complete and submit each incident report to CCLD within 7 days if non-serious and within 24 hours for serious incidents such as death, AWOL or outbreaks. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility does not follow reporting requirements is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.