Complaint·March 27, 2026

Allegation: Staff neglected to provide proper care and supervision to residents,resulting in injury . It was alleged that on 5/11/25 at 1:00 PM in the dining area, R1 was observed with bruising around their eyes. R1 was questioned by the their responsible family member (F1) and R1 stated that the facility is awful, that someone probably punched R1, but refused to provide additional details. Staff revealed that they provide wellness checks to R1 a minimum of every two hours. R1 is under staff observation in the common areas and is being assessed and supervised as frequently as necessary. Staff explained that on 05/05/2025 during lunch time R1 got too close to the Resident#2 (R2), and accidentally touched R2. By the time staff went to redirect R1, R2 grabbed the plate from the table and threw it at R1; Staff immediately separated R1 and R2. Staff revealed that R1 had a health condition triggering behaviors that could disturb other residents. Therefore, they were always monitoring R1. Staff stated that R1 did not have fall incidents that could cause bruise around their eyes. LPA was unable to communicate with R1 due to R1’s inability to respond to questions. Other residents interviewed during investigation did not address any concerns regarding the assistance provided by facility staff. A review of facility records verified the information received from staff. Based on the information obtained through observation, records review, and interviews, it was concluded that although R1 may have been involved in the incident, causing injuries, there is not sufficient information to conclude that staff neglected to provide required care and supervision to R1. Hence, the allegation is UNSUBSTANTIATED at this time. Allegation: Resident’s pressure wound worsened due to staff neglect - Concerns were addressed that a prior bed soar, above R1’s buttock had worsened and appeared to be 6 inches long by 3 inches wide. Four months ago, the wound was much smaller. Staff revealed that R1 had a wound on their buttock and was receiving home health care services for wound care. As per Staff’ observation, and the information received from home health nurses, the wound was healing. A review of R1’s home health care records verified that R1 wound was responding to treatment and healing. During investigation, LPA Comer was able to observe R1’s wound, finding the skin to be dry and wound healing well. [LIC 9099C] Continued- Based on interviews, observation, and record review, there is not sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff were distracted by their personal phones and not meeting the needs of residents - Complainant alleges that staff neglected to assist R1 with toileting assistance as they [staff] were instead distracted using their cell phones during working hours. During initial and subsequent visits, LPA conducted multiple tours of the facility in the morning and afternoon shifts and observed the following: Staff were witnessed providing consistent care and assistance to residents; no residents were witnessed by LPA as neglected by staff. During LPA interviews with Administrator and staff, they refuted this allegation, stating that staff provide assistance to residents in care on a consistent basis. Staff stated that if they need to make a phone call while working their shift, they will ask co-staff to provide temporary coverage until they return to their work duties. Residents’ interviews revealed that staff provide resident care and supervision on a consistent basis and that resident assistance was not neglected due to staff's personal issues. Based on the information LPA obtained through observation, and interviews with staff and residents, It cannot be proven that staff neglect to meet residents needs, nor are distracted by personal matters. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of report was issued.