Complaint·June 18, 2026

The investigation reveals the following: “Staff does not follow the resident's care plan. “It is alleged that staff have not been following R1’s new care plan since March of this year, which requires the facility to check on R1 4 times a shift. According to the administrator, the staff checks on R1 4 times a shift, but R1 does not like the staff in their rooms, and they are one of their independent residents. Staff check on R1 in the morning while R1 is sleeping, but don’t wake R1 because they don't like it. The administrator further stated that when R1 is out in the facility, staff visually check on them. All interviewed staff denied the allegation, stating that when R1 is around the facility, they visually check on R1. 1 out of 10 residents stated that although they are around the facility, they prefer staff to physically address them for it to count as a check. 9 out of 10 residents denied the allegation, stating that staff provide great care. LPA reviewed R1’s care plan and noted that it stated 4 times per shift, but it did not outline who conducts the checks or how they are to be conducted when the resident is not in their room. LPA also reviewed the document provided by R1, titled "Communication with Administrator." The document contained the dates and initials of night-shift staff who signed off, confirming they conducted checks on R1. When the document was presented to the administrator, they stated that it was not an internal document and that they had not seen it. The administrator stated that the signatures resembled R1’s handwriting and that staff had not informed them of the document. LPA attempted to contact the staff listed on the document and left a message for a return call. The investigation reveals the following: “Resident sustained several injuries due to staff neglect or physical abuse. “It is alleged that R1 received head trauma, fell, broke their nose, and had to be in the hospital. The administrator denied the allegation, stating that in February, the residents had a fall and bruised their faces, but refused to go to the doctor. The administrator stated that R1 eventually went to their own doctors and refused to provide the facility with discharge paperwork. 1 out of 4 staff members stated that when they checked on R1, they saw a bruise, and R1 refused to go to the doctor. They contacted the medtechs to check on R1. 1 of 4 staff members reported that R1 had a fall in February, resulting in a bruise. They further stated that R1 didn’t call anyone because R1 was drinking, and they believed R1 felt embarrassed. All staff denied neglecting or abusing the residents. 10 out of 10 residents denied that the facility neglected or abused them. Report continued on 9099c The investigation reveals the following: “Staff is not following reporting protocols as necessary. “It is alleged that the facility currently has a scabies outbreak and has a quarantine notice on residents' doors, but it was not reported to the health department or licensing office. Prior to the visit, LPA reviewed the facility's incident reports and did not note any incidents related to a scabies outbreak. The Administrator denied that there is currently a scabies outbreak but confirmed that there had been one in the past. During that time, the administrator stated that they had reported to the appropriate agencies. When asked about the isolation rooms, the administrator stated that no one is in isolation. All staff interviewed denied that the facility currently has scabies cases, but confirmed past outbreaks. 1 out of 10 residents stated R3, R4, and R11 have scabies. 3 out of 10 residents stated that they believe R11 may have had scabies for a couple of months due to a rash. 1 out of 10 stated they believed they had scabies. 1 out of 10 stated they are not sure if there are any current cases of scabies. 5 out of 10 stated there are no current cases of scabies. LPA toured the facility with the administrator and observed two resident rooms with bins in front of each room. The administrator stated they are not for isolation. LPA interviewed the residents in those rooms and did a file review to confirm they do not have scabies. LPA also conducted a file review for R3, R4, and R11 and did not observe a scabies confirmation from a physician. Based on LPA's interviews, the investigation revealed that, although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Alisa Dean, and a copy of this record was provided.