complaint·October 16, 2025

Regarding allegation: Staff left resident in the sun for an extended period of time causing sunburns . It is alleged that R1 was left outdoors for a long period from morning to late evening. Staff did not ensure R1’s safety which caused R1 to get sunburn on her body. The investigation reveals the following: Residents interviews reveal that ten (10) out of ten (10) residents denied the allegation above. Staff interviews reveal that seven (7) out of seven (7) staff denied the allegations above. Residents responded that residents prefer to remain indoors, and residents are not aware of other residents being left outside for long period of time. Residents’ interviews reveal that residents who are observed to be outside are monitored by staff. S2 stated that staff provide hats, sunscreens, or move residents to shaded areas to prevent sunburn. S4 stated that R1’s has not been observed with any skin bruises, rashes, or tears during morning or evening shifts that would indicate any sun damage. Record review revealed that recent hospital visit on 10/02/2025 did not change any current medications or indicate any new prescription for any skin damage. Based upon investigation, client and staff interviews, and LPA observations, there was no evidence that R1 has been left out exposed in the sun for long period of time that may have caused sunburn. Regarding allegation: Staff handle resident roughly when assisting with oral care. It is alleged that staff has hurt R1 by forcefully removing dentures. The investigation reveals the following: Residents interviews reveal that nine (9) out of ten (10) residents denied the allegation above. Residents stated that staff were considerate of their needs when helping with activities of daily livings (ADLs) such as transferring, toileting, or showering. Residents stated that staff were not rough when assisting residents with removing devices such as dentures. Staff interviews revealed that seven (7) out of seven (7) staff denied above allegation. S1 or S2 denied knowing any staff being rough when assisting residents with prosthetic devices. R1 interview reveals that R1 feels pain in the gums because R1 has been losing teeth. R1 did not express that staff were causing pain. S4 stated that dental appointment had been made but dental appointments were cancelled twice to assist R1 with other medical needs. Based upon the investigation, client and staff interviews, and LPA observations, staff did not handle resident rough when assisting with oral care and staff is assisting with dental appointments to meet R1’s dental needs. Report continues on page LIC-9099C... Regarding allegation: Staff take residents blankets away. It is alleged that staff forcefully removed R1’s blanket while R1 was sleeping. The investigation reveals the following: Residents interviews reveal that nine (9) out of ten (10) residents denied the allegation above. Residents stated that staff were considerate of their needs when helping with activities of daily living (ADLs) such as transferring, toileting, or showering. Residents stated that staff treat them respectfully and are not rude to residents. Three residents stated that there is no other place the residents would like to be. Residents stated that none had experienced staff pulling their blanket or pillows away from them. Staff interviews revealed that seven (7) out of seven (7) staff denied above allegation. S1 and S2 stated that community policy allows staff anonymous reporting. S1 stated that community administration does not tolerate staff mistreating residents and an investigation would be initiated. S1 stated that staff would be transferred to other duties during investigation. S1 stated that there has been no recent staff report of staff mistreating any residents. Based upon the investigation, client and staff interviews, and LPA observations, there is no evidence to show that staff are handling residents in an unprofessional manner by pulling residents blanket away. Regarding allegation: Resident fell and staff did not address the residents injury. It is alleged that R1 fell causing a left bruise on her ankle and staff did not ensure R1 received proper care for injury. The investigation reveals the following: On discharge hospital documents dated 10/02/2025, R1 was taken to hospital to get X-ray and there was no ankle injury found. S2 and S4 identified hospital visit on 10/02/2025 as a result of R1’s fall. Interview with S2 indicates that R1 participates in a care plan where a nurse practitioner visits R1 twice a week and a doctor visit once a month for residents who are not easily able to attend appointments. S2 and S4 stated that R1 complains of pain whenever someone touches her. S2 and S4 denied refusing to provide medical assistance to R1 for her pain. The Community has licensed nurses on site and S1 stated that it is community policy to have nurse attend residents who have fallen. An assessment is made, and licensed nurse may decide to transport resident to hospital. The community will call the party responsible and doctors who may decide to transport residents to hospital even if license nurse assessment did not recommend transport to hospital. Residents’ interviews reveal that ten (10) out of ten (10) residents denied the allegation above. Report continues on page LIC-9099C... A resident (R10) described two incidents where resident fell and nurse immediately responded and stayed with resident until paramedics arrived. Ten (10) out of ten (10) residents stated that staff is responsive to residents medical needs. Staff interviews reveal that seven (7) out of seven (7) staff denied the allegations above. Staff is responsive to residents call for help and provide medical assistance as needed. Staff interview revealed that staff is not aware of any other staff refusing to provide medical assistance to residents. Based upon the investigation, client and staff interviews, document review, and LPA observations, the staff provided medical assistance to residents and has an operating plan to handle residents falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was held with Director Keith Kasin. A copy of the report was provided.