complaint·October 8, 2025

Allegation: Resident was left down on the floor for an extended period of time after falling. The complaint alleged that a resident was hospitalized after being on the floor for more than 12 hours. On October 8, 2025, at approximately 9:00 AM, LPA Richard interviewed the Administrator (A1), who stated that the resident had been at the facility for just over three weeks. During the first three days of the resident's stay, R1 began exhibiting behaviors that were not previously disclosed during the pre-assessment. LPA Richard also interviewed two staff members, referred to as Staff #1 and Staff #2 (S1-S2), who reported that the resident would slide down from the bed to the floor and yell and scream. LPA interviewed one resident (R2) who stated that R2 likes living there, and the staff helps R2 when requesting assistance. On May 7, 2022, the staff had to call 911 to take the resident to the hospital due to R1 shouting and screaming; this was the last time the resident was at the facility. On October 6, 2025, LPA Richard contacted the Reporting Party to gather more information about the complaint filed with the department; however, the Reporting Party was no longer working there, and no additional information was provided. On October 8, 2025, LPA Richard interviewed the social worker from the Placement Agency, Innovage (PAI), but was unable to obtain any information about the resident's whereabouts. On October 08, 2025, LPA was unable to interview resident #1 (R1) due to R1's whereabouts being unknown. Based on the evidence gathered, interviews conducted, the preponderance of evidence standard has not been met. Although the 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, the above-mentioned allegation is found to be UNSUBSTANTIATED. Allegation #2: Staff did not prevent self-harming behavior. The complaint stated that resident R1 had a blanket wrapped around their neck and expressed a desire to harm themselves. On October 8, 2025, at approximately 9:00 AM, LPA Richard interviewed the Administrator (A1), who mentioned that R1 had been at the facility for just over three weeks . During the first three days of R1's stay, R1 began exhibiting behaviors that had not been disclosed during the pre-assessment, including yelling, screaming, and expressing a desire to harm themselves and others. This behavior prompted the staff to call 911 on May 7, 2022. LPA Richard also interviewed two staff members (S1 and S2), who confirmed that R1 would frequently yell, shout, and scream, and the staff felt the necessity of calling 911 to take R1 to the hospital. This incident marked R1's last time R1 was at the facility. LPA interviewed one resident (R2) who stated that R2 likes living there, and the staff helps R2 when requesting assistance. On October 6, 2025, LPA Richard contacted the Reporting Party to gather more information regarding the complaint filed with the department. However, the Reporting Party was no longer employed at the place where the phone number was provided, and they could not provide any new information. On October 8, 2025, LPA Richard interviewed the social worker from the Innovage placement agency, who was also unable to provide any information about R1's whereabouts. On October 08, 2025, LPA was unable to interview R1 due to R1's whereabouts being unknown. Based on the evidence gathered, interviews conducted, the preponderance of evidence standard has not been met. Although the 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, the above-mentioned allegation is found to be UNSUBSTANTIATED. No deficiencies cited. An exit interview was conducted, and a copy of the Complaint Report was given to the staff, Orlando Trajico.