complaint·December 30, 2025

It was alleged that a facility staff spoke inappropriately to R1 after she sustained her unwitnessed fall. LPA conducted an interview with R1 who confirmed the allegation and stated that a facility staff insulted her after she sustained her unwitnessed fall. LPA conducted an additional five resident interviews regarding their experience with facility staff. Two out of the five residents interviewed stated that a facility staff has also spoken to them in an inappropriate manner such as with rude or mean comments. However, three of out of five residents interviewed denied staff ever speaking to them in an inappropriate manner and stated that they believe staff are friendly. LPA also conducted five staff interviews. Two out of the five staff interviewed denied the allegation and stated that they have never witnessed or heard of staff speaking to a resident in an inappropriate manner. However, three out of the five staff interviewed confirmed the allegation. The three staff stated that they are aware of previous incidents in which a staff has spoken to a resident in an inappropriate manner. Additionally, two of the staff interviewed stated that they have personally witnessed a staff speak inappropriately to a resident. LPA conducted a total of eleven interviews for this complaint, including interviews with residents and staff. Out of the eleven people interviewed, six people corroborated the complaint allegation. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff inappropriately communicate with resident. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Assistant Administrator Kathleen Tamondong. A copy of the report and Appeal Rights were provided. It was alleged that facility staff did not attend to Resident #1 (R1) in a timely manner after she sustained an unwitnessed fall on an unknown date. LPA reviewed the facility's charting notes and observed that R1 had a documented fall at the facility on November 24, 2025, at approximately 3:50 AM. 9-1-1 was called and R1 was transported to the hospital. LPA conducted an interview with R1. R1 said that she had rolled out of her bed and that she was on the floor for approximately one hour before a facility staff found her. R1 said that because of her condition, she was unable to pull the call cord in her bedroom that would have alerted staff. LPA conducted an interview with R1's roommate, Resident #2 (R2). However, R2 was unable to provide any information on how long R1 might have been on the floor before she was assisted by a facility staff. LPA conducted five staff interviews. Two out of the five staff interviewed were unable to provide any useful information for the complaint allegation. Three out of the five staff interviewed denied the allegation and stated that R1 was assisted in a timely manner after she sustained her unwitnessed fall. LPA conducted an additional three resident interviews. Three out of the three resident interviewed stated that staff have always helped them in a timely manner. Due to conflicting information gathered during this investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of the report was provided.