complaint·September 17, 2025

(Continuation from LIC9099) The report alleges staff were unable to provide emergency personnel with resident census. Interviews conducted with the Fire Department Representative and facility staff corroborate that Emergency Personnel were requesting a verbal head count of all residents to ensure all residents were accounted for. The Fire Department Representative reported the facility staff provided the Fire Department with a verbal head count when requested on 03/14/2025. The Fire Department Representative further explained facility staff provided a response to all of the Fire Department’s requests promptly and/or within a timely manner to the situation. It was alleged facility staff were unable to provide emergency personnel with resident records. Interviews conducted with the Fire Department Representative and facility staff corroborate that emergency personnel did not request resident records on 03/14/2025. Interviews with facility staff reported facility staff attempted to provide the Fire Department with the facility’s emergency disaster plan. Facility reported that Fire Department personnel declined to review the disaster plan. Interview with the Fire Department Representative revealed resident records are only requested when a resident may require medical attention. Facility staff and the Fire Department Representative corroborated that Emergency Medical Services were not requested and/or needed for any resident at the time of the incident on 03/14/2025. It was alleged staff did not execute evacuation plan. Record review revealed facility’s Emergency and Disaster plan outlines facility assembly point to be in the front of Building A by the flagpole and residents will be relocated to locations outside the facility as needed. Through interviews with facility staff and the Fire Department Representative, the facility staff evacuated all residents to the assembly point outside of Building A. The evacuation was a result of an incident that occurred on 03/14/2025 in Building B. Interviews with both facility staff and the Fire Department Representative revealed facility staff were instructed, by fire personnel, to relocate the residents from Building B into Building A. No additional relocations were required. It was alleged facility did not have adequate staff to meet the needs of the residents in care. It was reported the facility did not have enough staff to assist with the evacuation of residents. Interviews conducted with the Fire Department Representative, facility staff, and residents, corroborate that there was sufficient staffing on duty to assist with the evacuation of residents in Building B. Record review and interviews conducted for staff schedule verified (4) four staff were on shift during the evacuation. During the incident, an additional 2 staff arrived to assist in evacuating the 42 residents. These additional staff arrived prior to the arrival of the fire personnel. (Continue to LIC9099C) (Continuation from LIC9099C) A review of the fire department’s Incident Report dated 03/14/2025 revealed the alarm was activated at 6:49PM and they arrived at 6:59PM. Fire Department Representative indicated when fire personnel arrived almost all residents were evacuated. The representative could not provide the specific number of residents who still required evacuation when fire personnel arrived. The interview with the Fire Department Representative revealed there was a sufficient number of staff to evacuate the residents in care. Based on information obtained from interviews and record reviews, the evidence received pertaining to the allegations listed above, are deemed unfounded. A finding of unfounded means the allegations could not have happened or are without a reasonable basis. An exit interview was conducted where a copy of this report was discussed and given to Wellness Director, Haley Logan.