Complaint·August 15, 2025

During this incident a staff member was in her designated live in quarters sleeping and was made aware of the altercation after R2 knocked on her door. Staff member was awakened and began to intervene. It was further revealed through interviews and record reviews that although staff member was physically inside the facility, staff member was not present for purposes of immediate intervention. Additional interviews and record reviews revealed that additional supervision was necessary during this time period due to various resident activity leading to potential threats to other residents’ physical, verbal, and resident rights. As a result, it is determined that a lack of appropriate supervision was not in place during this time period and was necessary to initially address the altercation before further escalation. Based on evidence reviewed, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Allegation: Staff do not assist residents during the night hours. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that although a staff member lives in the facility and occupies a separate living quarter, facility did not schedule a staff member for on-call care and supervision duties between the hours of 11pm and 7am. A review of facility’s LIC 500 personnel report dated 6-17-2025 indicated no on-call staff between 11pm and 7am. Interviews and record reviews further revealed various episodes prior to the above date in which resident2 (R2) required physical assistance at night and told there was no staff available to assist. Additionally, it was revealed through interviews and other evidence that various resident activity within facility occurred between 11pm and 7am prior to the above date which led to potential threats of residents’ physical and mental well-being as well as personal rights. This included a resident in care identified by staff as infringing on rights of other residents during the day, with same resident awake between 11pm and 7am ambulating throughout facility with no staff scheduled on duty. As a result, it is determined that the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Based on this investigation, citations are issued under Title 22, division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.