complaint·December 18, 2025

Two of five additional residents were unable to confirm or deny allegation. Regarding the allegation, Resident sustained unexplained bruising while in care, the following was revealed: it is alleged R1 sustained unexplained bruising. Per Incident Report (LIC624), on February 10, 2025 at 2:40 a.m., R1 stood up and threw themselves on the floor hitting their head on their wheelchair in the process. Per Narrative Charting for R1 dated February 10, 2025, paramedics were called and upon R1’s return from the hospital, R1’s responsible party, W1 observed bruising on R1’s right forearm. The Department obtained pictures of the bruising on R1’s forearm, which was observed to be round in shape and approximately the size of a quarter. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R1 denied the allegation and pulled their shirt back by the neck and pointed to a scab the size of a thumbtack right below their neck. R1 stated the scab was from thousands of mosquitos and does not go away because they scratch it, and the scab comes off but it always comes back. During their interview, R2 stated they had sustained a bruise and pointed to a round, quarter size spot of discoloration on their forearm. Per R2, the bruising was from the hospital, when they attempted to insert an IV. LPA observed discoloration on R2’s forearm to be consist in size and shape as that of R1’s bruising. Interviews were conducted with four additional facility residents. One of four residents was unable to confirm or deny allegation and three of four residents denied sustaining unexplained bruising or having any knowledge of any other resident sustaining unexplained bruising. Regarding the allegation, Staff did not provide adequate supervision resulting in resident sustaining multiple falls, the following was revealed: it is alleged staff did not provide adequate supervision resulting in R1 sustaining multiple falls. During the course of the investigation, LPA conducted record review of Incident Reports (LIC624) submitted by the facility to Community Care Licensing (CCL), and observed four incidents in which it was reported R1 sustained a fall from December 3, 2024 to February 10, 2025, with two of the incidents taking place on the same date, February 10, 2025. Per Narrative Charting for R1 dated December 3, 2025, R1 as found on the floor in a sitting position and noted redness on one side of R1’s back with no other visible injuries. R1 was monitored through the shift and observed to be doing well. On December 20, 2024, R1 was found on the floor right next to their wheelchair. Redness was observed to R1’s back toward the upper side. R1 reported pain to the touch on the redness on their back and a PRN for pain was administered. On February 10, 2025, at 2:40 a.m., R1 stood up and threw themselves on the floor hitting their head on their wheelchair in the process, paramedics were called and R1 was transported to the hospital. (Cont. LIC9099-C) R1 returned from the hospital on the same date and later that night, R1 was found on the floor and bruising was observed to R1’s right upper arm and R1’s responsible party was notified. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R1 denied sustaining a fall at the facility. Regarding the allegation, Staff did not notify resident's responsible party of change in resident's condition, the following was revealed: it is alleged staff did not notify R1’s responsible party of R1’s change in condition. During the course of the investigation, LPA conducted record review of Incident Reports (LIC624) submitted by the facility to CCL, and reviewed facility Narrative Charting for R1 and observed R1’s responsible party was notified following all incidents involving R1. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R1 was unable to confirm or deny allegation. Interviews were conducted with five additional facility residents. One of five residents was unable to confirm or deny the allegation and four of five residents stated their responsible party is notified of any changes in their condition. Regarding the allegation, Staff did not safeguard resident's personal belongings, the following was revealed: it is alleged staff did not safeguard R1’s hearing aids. During the course of the investigation, interviews were conducted with R1, five additional facility residents and three staff. During their interview, R1 stated their hearing aids are stolen, and they are given "junk" and then the "junk" gets stolen. R1 identified “the neighbor of the guy that orders [their] hearing aids” as the individual stealing the hearing aids. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R2 stated they had cash go missing in the last day or two, however, stated they had yet to report the missing cash to facility staff. During their interview, R3 denied having any personal belongings stolen or missing, however, did recall R1 would often misplace their hearing aids and staff would assist them in locating them. Per R3, R1’s hearing aids would frequently be found in R1’s pocket or amongst R1’s personally belongings. Two of three additional residents interviewed were unable to confirm or deny the allegation, and one of three residents denied having any personal belongings stolen or missing. Three of three staff interviewed stated R1 would frequently remove their hearing aids and misplace them, however the hearing aids would eventually be located amongst R1’s personal belongings or in their laundry basket. (Cont. LIC9099-C) Based on record review of R1’s Narrative Charting, LIC624s, and MARs, and due to the allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff did not ensure resident received medication as prescribed, if Resident sustained unexplained bruising while in care, if Staff did not provide adequate supervision resulting in resident sustaining multiple falls, if Staff did not notify resident's responsible party of change in resident's condition, or if Staff did not safe guard resident's personal belongings. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.