complaint·June 26, 2025

Continued LIC9099-C page 2 The investigation revealed the following: Allegation 1: Staff failed to prevent a resident from sustaining a fracture while in care. It was alleged that on October 24, 2024, R1 exited the facility, began walking backward, and subsequently fell, sustaining a hip fracture. R1 was transported to the emergency room and diagnosed with the injury. LPA interviewed Staff #1–5. 1 out of 5 staff members stated they were not present during the incident and could not provide details. 4 out of 5 staff members confirmed they were present and described that R1 was attempting to leave the memory care unit. R1 exited through a secured door and began walking backward, which led to the fall. Staff arranged transport to the hospital for medical evaluation. LPA interviewed Residents #2-8 (R2–R8), and 7 out of 7 residents denied the allegation. LPA conducted a tour of the physical plant, but no surveillance cameras were observed. A review of R1’s file, including the Physician’s Report, Needs and Services Plan, and Preplacement Appraisal, did not indicate a documented history of falls. An incident report was submitted to Community Care Licensing (CCL) for the incident that occurred. Based on the investigation, there is not enough evidence to support that staff failed to supervise R1, resulting in the resident sustaining a fracture. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 allegation is deemed unsubstantiated. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation 2: Staff failed to prevent a resident from eloping from the facility. It was alleged that on October 24, 2024, R1 exited the facility without staff supervision. LPA interviewed Staff #1–5. 1 out of 5 staff members was not present during the incident but reported hearing that R1 never left the facility premises. 4 out of 5 staff members confirmed their presence during the incident and stated that while R1 exited the memory care unit, the resident did not leave the facility grounds and was under supervision at all times. LPA interviewed residents #2-8 regarding the allegation, 7 out of 7 residents denied the allegation. LPA conducted a tour of the physical plant and observed the facility's memory care unit is located on the second floor of the building. Based on LPA’s observation if a resident exits the memory care unit they would be in the hallway and would need to take an elevator down from the second floor to completely exit the facility premises. Based on the investigation there is no evidence to support R1 eloped from the facility grounds. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Memory Care Director Denyanna Banda. An exit interview was conducted. No deficiencies were cited.