complaint·June 18, 2025

On 06/18/2024, LPA interviewed Staff# 8 - Staff# 10, requested a copy of the LIC 624: Unusual Incident Injury for R1-R2 (dated 12/21/2024) and staff schedule (December 2024). The investigation revealed the following: Allegation: Lack of supervision resulting in resident being assaulted by another resident while in care. On 04/03/2025 between the hours of 12:18pm - 12:28pm, LPA interviewed the Administrator (A1), regarding the above allegation. A1 stated she was unaware of the allegation. On 04/03/2025 between the time of 9:31am - 12:28pm, LPA interviewed Staff # 1 (S1)– Staff 6 (S6) and on 04/23/2025 between the hours of 9:21am – 9:38am, LPA interviewed Staff (7) regarding the allegation. On 06/18/2025, between the hours of 10:53am - 12:05pm, LPA interviewed Staff #8 (S8) - Staff #10 (S10) regarding the allegation. 3 out 10 staff interviewed confirmed an incident occurred between Resident #1 (R1) and Resident #2 (R2), but Staff had different various of the incident that occurred between R1 and R2. 7 out 10 staff interviewed had no knowledge of the incident that occurred between R1 and R2. On 04/03/2025 between the hours 1:17pm - 2:26pm, LPA interviewed Resident #1(R1)  – Resident #5 (R5). On 04/03/2025 LPA attempted to interview Resident# 1 (R1) but due to the communication barriers, the resident was unable to answer interview questions. On 04/03/2025 LPA attempted to interview Resident #2 (R2) who declined to be interviewed. Report continues on LIC 9099-C 5 out of the 5 residents interviewed were unaware of the incident. On 05/06/2025 between the hours of 2:30pm – 3:30pm, LPA conducted a records review for Resident #7 (R1) records and observed the following: No history of aggravation per the resident’s physicians report (dated 09/29/2023) and need and service plan (dated 10/30/2024) No history and or record of LIC 624: Unusual Incident/Injury Report (from December 2024 – April 2025) On 06/18/2025, LPA returned to the facility and conducted a records review of the staff scheduled (December 2024) during the time of the incident. On the date of the incident 12/21/2024 at approximately 4:45pm, seven (7) staff worked between the hours of 8:45am - 6:12pm. On shift, there were a total of 6 Caregivers, 1 Medtech and Administrative Staff. During the time of the incident, the facility had a census of 61. This incident is the first occurrence between R1 and R2. No similar incidents were reported for R1 and R2. The incident occurred suddenly which did not allow the staff to prevent the incident from occurring at the time Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above.  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 allegation is unsubstantiated. Exit interview conducted with Joel Niblett, Administrator Designee & copy of the report was provided.