Complaint·February 26, 2026

Allegation: Staff did not assist resident in a timely manner . It was reported that R1 was admitted to the hospital due to a fall incident resulting in subdural hematoma. R1 had a history of multiple falls. The Administrator and staff stated that on 04/29/25, at around 7PM, R1 had an un-witnessed fall in their bedroom. R1 was found on the floor by staff #1 (S1). R1 told S1 that they slid down from bed. S1 assessed a resident, offered to send them to the hospital and R1 refused. Later, R1 complained of headache and agreed to go to the hospital. Upon returning to the community, R1 was monitored to prevent possible falls. S1 and other staff verified the information revealed by ED. Staff present in the facility deny neglecting R1 or other residents, indicating that R1, and other residents, are observed and assessed as per their needs and service plan. Most residents are being checked every 2 hours, and more often if needed. Other residents interviewed during investigation had no concerns regarding their care and supervision. An interview of a witness did not reveal any information to support the allegation. A review of R1’s facility file and incident reports verify the information revealed by staff. Based on interviews and record review, it was concluded that although the allegation may have happened, there was not sufficient information to verify validity of the complaint. Hence, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not assist resident(s) in a timely manner . Concerns were addressed that staff take long time to respond to a resident #1 (R1) for assistance. R1 alleges waiting for help sometimes 30 minutes, to 2 hours. LPA interviews with Staff revealed the following: Staff stated that their response time to the residents’ requiring assistance is ten (10) minutes on average. Residents interviewed during investigation had no concerns regarding timely assistance. During physical plant inspection, LPA checked call buttons from the residents’ rooms and staff responded within 10-12 min. Records reviewed by LPA did not reveal any information to verify the allegation. Based on inspection, observation, interviews and record review, there is insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. [LIC9099C] Continued- Allegation: Staff physically force-fed resident medication . It was reported that while R1 was complaining of pain, two (2) nurses came to R1’s room and offered a Tylenol, which R1 refused; Staff forced the pill into R1’s mouth. During investigation, staff denied force-feeding medication to R1, or any other residents. The residents interviewed during investigation did not address any concerns regarding their medication assistance. A review of R1’s medication records revealed that R1 had pain medication (Tylenol) as a PRN and it was dispensed to R1 as needed. No verifiable information was available during this investigation to support the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff hit and mishandled the resident . It was reported that staff are rude to R1. They physically strike R1. While changing R1, Two (2) staff slammed R1 against the wall and pushed their head between the rails of the bed. The Administrator and staff denied being rude, mishandling and/or hitting any residents. Residents interviewed during investigation stated that staff assist residents with respect, are gentle, and never hit anyone. Facility records did not provide any information to verify the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not provide sufficient activities for resident . It was reported that staff do not give R1 enough therapy like walking around etc. The Administrator and staff stated they provide activities in the morning, in the afternoon and before bedtime. All residents are notified of scheduled activities, and it is their choice if they want to participate. Residents verified the information provided by the staff. A review of activity schedule verified that throughout the day, facility provides different activities to all residents. During investigation, LPA Comer observed residents participating in various activities. Overall investigation did not reveal any sufficient information to support the allegation.