complaint·January 30, 2026

Assistant Administrator will send remaining pertinent documents by COB. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On 12/11/2025, a subsequent investigation visit was conducted. The investigation consisted of the following: LPA obtained the following documents: staff and resident rosters, R1’s Physician’s Orders and Hospital Discharge Notes. LPA interviewed the Executive Director, Assisted Administrator, Staff #1 (S1) to Staff #4 (S4), Resident #2 (R2) to Resident #6 (R6). LPA obtained Staff In-Service documents. During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Executive Director over the phone. The investigation revealed the following: in regard to the allegation, “Staff did not follow a physician's instruction resulting in a resident falling and sustaining a fracture.” It is alleged that on March 23, 2025, R1 fell and was sent to the Hospital and was diagnosed with a fractured wrist. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Salant. LPA reviewed IB interviews which revealed the following: While R1 had a history of falls, there were no doctors’ orders requiring R1 to have bed rails on R1’s bed, be on a 1:1 supervisor, or any type of special orders for fall prevention. The staff acted timely and within the guidelines of their training in response to R1’s last fall, which ultimately led R1 to being hospitalized. In addition, staff followed the directions that were current, to the best of their knowledge, and at the time R1 fell, investigator Salant did not feel there was anything that could have been done differently that would have produced a different outcome. There is not enough evidence to substantiate. Allegation: “Staff refused to accept a resident back into the facility.” It is alleged that when R1 was ready to be discharged from the hospital, the facility would not take R1 back and R1 was forced to go to a rehabilitation center and not allowed to return to the facility. LPA interviewed two (2) out of five (5) residents that denied the allegation stating that when the resident was hospitalized and to be discharged from the hospital, the staff checked the resident to make sure the resident was able to return back to the facility. LPA interviewed three (3) out of five (5) residents that could not confirm nor deny the allegation stating they could not remember if they were ever refused to return from the facility. [Continue in LIC9099-C] LPA interviewed the Executive Director, Assistant Administrator, and one (1) out of four (4) staff that denied the allegation stating that when residents are hospitalized, the staff visits the resident at the hospital prior to assessing and determining if the resident needs higher level of care, rehabilitation, or return back to the facility. Three (3) out of four (4) staff could not corroborate nor deny the allegation since they all stated they are not involved in the acceptance of residents after being discharged from the hospital. The Executive Director and Assistant Administrator stated that on 03/23/2025, R1 was admitted to the hospital on 03/23/2025 and was discharged from the hospital on 03/24/2025 and transferred to the rehab center because R1 had to have rehab for the fractured wrist and provided physical therapy at a SNF prior to return to the facility. LPA obtained and reviewed Hospital Discharge Notes dated 03/24/2025 which indicated based on R1 is stable for discharge to skilled nursing facility (SNF) for further OT/PT. Per interview with the Executive Director, facility’s intention was to accept R1 back to the facility after the rehab is completed. Executive Director also stated that the facility did not refuse to accept R1 back to the facility since the Executive Director visited R1 at the SNF to assess R1 on 04/03/2025 to determine the status if R1 is clear to return back to the facility or require more rehabilitation. However, the facility was not able to assess R1 since R1 passed away on 04/03/2025 prior to being re-assed by the Executive Director. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation 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 allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Residential Care Specialist, Leonard Wynne.