complaint·February 12, 2026

Facility is understaffed Interviews conducted with Staff Members S1, S2, S3 and S4 indicated that care is being provided adequately to all residents in care. It was indicated that staffing is increasing and overall care is easier to manage with the current number of staff. S1, S2, and S3 indicated that they would like one more staff on the floor for the morning AM shift but are able to still complete all tasks assigned. Records reviewed indicated that there are staff on each shift to assist the residents in care and staff schedule indicates an increase in staff over the last few months. Therefore, the allegation inadequate staffing to provide care is unsubstantiated. Staff did not prevent resident on resident altercation LPA reviewed LIC624 and SOC341 reporting that R2 assaulted R1 on 10/20/2025. Staff who were interviewed stated they did not witness the incident. Staff were quick to respond after incident had occurred and called 9-1-1 on behalf of R1 to get R1’s injuries assessed. Executive Director stated that the two residents were inside R1’s room when R2 pushed R1 resulting in R1 falling to the ground. It was determined that this incident did occur and was reported by the facility to licensing and R1’s power of attorney. However, there is no regulation that has been violated and as a result a citation cannot be issued for this allegation. Therefore the allegation staff did not prevent resident on resident altercation is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Staff negligence resulted in resident sustaining fall w/ injuries Records reviewed indicated that R1 sustained a fall on 10/18/2025 in their room. R1 sustained an injury to their left eyebrow and skin tears on forearm and hand. R1 utilizes the Safely You program which captures a video of any fall in the resident rooms. The incident was captured on 10/18, staff responded immediately after getting the fall notification and followed protocols by calling emergency services to have R1’s injuries assessed. Licensing and R1’s power of attorney (POA) were notified of incident. Interviews conducted indicated that R1 needed assistance at times with transferring and utilized a walker for mobility. R1 had 1 previous fall with no injuries on 8/28/2025 so R1 was considered a “fall potential” and not an immediate “fall risk”. Staff monitored appropriated based on R1’s service plan. Therefore, the allegation staff negligence resulted in resident sustaining fall w/ injuries is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.