Complaint·March 18, 2026

Allegation #1: Staff did not provide adequate supervision, resulting in a resident pushing another resident out of bed onto the floor. The complaint alleged that another resident became aggressive and pushed the client out of the bed onto the floor. The department interviewed the administrator (A1), who denied the allegation and stated that a staff member found resident #1 (R1) sitting on the floor next to the bed. A1 also mentioned that R1 has a history of scooting off the bed, so staff regularly checked on R1 and confirmed that no injuries were found. It was noted that R1 often tries to interact with other residents, though sometimes they are not receptive. Additionally, the department interviewed three staff members (S1, S2, S3), all of whom also denied the allegation. They reported that other residents enjoy playing with R1 and that R1's room is located across from several other residents. At the time of the incident, the staff noticed another resident (R2) in the room and attempted to ask for help. Upon inspection, no injuries were found, and the staff notified the responsible party about R1 sitting on the floor. The department attempted to interview R1 and R2 but could not gather any information due to their cognitive impairment. Meanwhile, resident #3 (R3) stated that R3 enjoys living in the facility and feels that the staff treats them well. Report continued on LIC9099C A review of the Unusual Incident Injury Report submitted to the Community Care Licensing Division (CCLD) by the facility on December 11, 2023, confirmed that R1 was found sitting on the floor near the bed. The department also reviewed several individual Team member dementia training courses with various titles. The department also attempted to interview the responsible party, but, they declined to answer any questions, stating that R1 had moved out of the facility two years ago and had no further information. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation (s) did or did not occur; therefore, the allegation is unsubstantiated . No deficiencies cited. An exit interview was conducted, and a copy of the report was given to Administrator Heather Segura.