Complaint·May 21, 2026

Regarding: Resident sustained an injury due to staff neglect. It is alleged that resident’s care plan which indicates that resident has to be checked four times per shift is not being followed which has caused resident to fall causing head trauma and other injuries. Interviews with (5) out of (8) staff indicated that staff are conducting wellness checks on residents according to their Care/Service Plan. Staff indicated that R1 is checked (4) times per shift by caregivers and staff from other departments as indicated by R1’s Care/Service Plan. Staff indicated that not only are wellness checks conducted in resident rooms, but also in the common areas and any place residents spend time in. Staff indicated that on 2/15/2026, R1 sustained injuries to their face after experiencing an unwitnessed fall but was sent to the hospital for evaluation and medical attention, shortly after S2 reported seeing R1 with bruising during response to a call from R1 via call button. Interview with S2 revealed that R1 was assigned to their wellness check rounds on the day R1 experienced the fall and had been checking on R1 approximately every two hours since the start of their shift. S2 indicated that before S2 observed the bruises on R1’s face, S2 had conducted wellness checks at around 10:00 p.m., 12:00 a.m., 2:00 a.m., 4:00 a.m., and then at 5:00 a.m. when R1 called for help. Staff further indicated that staff adhere to wellness check policy by checking on residents according to their Care/Service Plan. S1 and S4 indicated that R1 was released from the hospital on 2/17/2026; however, since R1 is self-responsible, R1 did not share hospital after-visit summary information with staff indicating diagnosis of head trauma. Staff indicated that they continue to monitor R1as stated in their Care Plan. Interviews with (11) out of (12) residents indicated that staff are conducting wellness checks according to their needs and have no concerns. Review of R1’s Care/Service Plan and current Physician’s Report indicated that R1 is self-responsible and manages their medical decisions. Staff and resident interviews and record review do not corroborate the allegation that resident sustained an injury due to staff neglect. Regarding: Staff do not answer call buttons. It is alleged that on 2/16/2026, resident fell out of bed during the night shift (NOC), pressed their call button, but nobody aided resident until 4:00 a.m. It is also alleged that staff did not answer their call due to staff sleeping during their shift. Interview with S1-S4 indicated that staff named on the report (S5) was not scheduled to work in R1’s wing during the NOC shift (10:00 p.m. – 6:30 a.m.) on the day R1 experienced an unwitnessed fall which took place on 2/14/2026 into 2/15/2026 and therefore, could not have been observed sleeping during shift. Interview with S2 revealed that on 2/14-2/15/2026, S2, and not S5, was assigned to conduct rounds in R1’s wing during the NOC shit. S2 stated that S2 checked on R1 at around 4:00 a.m. and observed R1 to be in bed, awake and covering their face with their blanket. ***Continues on LIC 9099-C page 2*** S2 stated that S2 asked R1 if they were okay due to R1 seemingly concealing their face with the blanket. R1 indicated to S2 that they were okay and did not need anything at the moment. At around 5:00 a.m., S2 indicated that R1 called the front office using their call button and S2 proceeded to immediately check on R1. During room visit, S2 noticed redness and bruising on R1’s face and when asked, R1 stated to S2 that they fell as they attempted to walk to the bathroom. S2 indicated that even though R1 did not want S2 to report the incident, S2 proceeded to inform med-tech staff who then proceeded to call 911 to have R1 transported to the hospital for further assessment. S2 further indicated that they were not sleeping during their shift and responded to R1’s call as soon as call came into the office. Interview with S3 indicated that as soon as S2 reported R1’s injuries, S3 checked on resident and called 911. S3 further indicated that before 6:00 a.m., resident was transported to the hospital for further treatment. LPA made several attempts to call S5; however, S5 did not answer. Staff informed LPA that S5 is no longer working at the facility due to retirement. Interviews with (11) out of (12) residents indicated that that staff are answering their calls in a timely manner. Residents also indicated that they have not observed staff sleeping during their shifts. Staff schedules reviewed by LPA indicated that S5 was not scheduled to work in R1’s wing nor was it assigned to S5 to provide care for R1 during the NOC shift on 2/14/2026 into 2/15/2026. SIR received by the department on 2/17/2026 indicated that R1 received care from staff after their fall and was sent to the hospital for further assessment. Staff and resident interviews and record review could not corroborate the allegation that staff did not aid resident after a fall and after calling for help. Regarding: Staff did not report outbreak to required agencies. It is alleged that the facility currently has an outbreak of scabies and has not notified the Health Department or Community Care Licensing. Staff deny the allegation. Interviews with (8) out of (8) staff revealed that the facility does not have an outbreak of scabies. Staff indicated that the facility is not currently experiencing an outbreak of scabies among staff and residents and therefore reports have not been made to the required agencies. Staff indicated that the facility has protocol in place to mitigate outbreaks when they appear among the facility population. Interviews with (11) out of (12) residents indicated that they have not had scabies nor have they heard other residents express concern about an outbreak. Residents indicated that the facility is kept clean and do a good job in preventing scabies and other communicable illnesses. Staff and resident interviews do not corroborate the allegation that the facility did not report an outbreak to the required agencies. ***Continues on LIC 9099-C page 3*** Based on information gathered through staff and resident interviews, LPA did not find evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated . Exit interview was conducted with Alisa Dean, Interim Executive Director and a copy of the report was provided.