Inspector’s narrative
What the inspector wrote
R1's two (2) discharge paperwork from hospital #1 (H1) and hospital #2 (H2), shift crossover notes (dated: 06/24/25 through 07/05/25) and LPA observed R1's injuries.
Please see LIC813-C. LPA attempted to interview R3 once more, R3 was not available for interview due to current medical condition.
LPA attempted to interview R4 & R5 and both were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview request.
Investigation revealed the following: Regarding the allegation, "Staff inappropriately restrained resident resulting in injury.", it is being alleged that a resident had redness on both forearms from being restrained by staff. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1&R2) and W1 have disagreed the allegation has taken place at the facility. R1 stated, "Two (2) of the guys near the hospital, grabbed me and stomped all over me.", which indicate the allegation has not taken place at this facility. Based on record reviews, LPA observation(s) and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been
Unsubstantiated.
Regarding the allegation, "
Staff handled residents in a rough manner.". It is being alleged that a resident was bruised by staff. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1-R2) and W
1 have disagreed the allegation has taken place at this care facility. R1 stated,
"
I guarantee to you that they didn’t do that here. That was at the hospital.
"
, which indicates that the staff at this care facility are appropriately trained to care for the elderly. Based on record reviews, LPA observation(s) and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been
Unsubstantiated.
Report continues, see LIC9099-C.
Regarding the allegation, "Staff did not ensure resident a safe environment while in care.". It is being alleged that a resident has been "beat up" at the home. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1&R2) and W1 have disagreed the allegation has taken place at this care facility. R1 stated,
"It's so good to be clean and safe here." and "Time here is wonderful, the staff are nice and the food is great. Everything is great here!". Based on LPA observation(s), record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been
Unsubstantiated.
There have been zero (0) deficiencies cited during today's visit.
An exit interview was held with staff two, Kathleen Mantes - Caregiver (S2), and a copy of this report has been provided.
