complaint·September 25, 2025

Allegation #1: Facility staff left resident on the ground for an extended period of time . The complaint alleged the facility left R1 on the ground for several hours after a fall on 11/15/2025 and 11/17/2025, and that no immediate assistance was provided. On September 25, 2025, between 9:00 AM and 11:30 AM, the Licensee (LPA) conducted interviews regarding an allegation. The Licensee denied the allegation, stating that the residents did not fall but rather sat on the floor and refused to get up. During the same time frame, LPA interviewed the Administrator (A1), who also denied the allegation. A1 explained that the staff is trained to assist residents in the event of a fall and to call 911 if there are visible injuries or if a resident complains of pain. Additionally, LPA spoke with the previous Administrator (A2), who similarly denied the allegation. A2 mentioned that Resident 1 (R1) prefers sitting on the floor and often refuses assistance when the staff attempts to help R1 get up. A2 emphasized that the facility respects the rights of the residents. LPA also interviewed three staff members during this time. Each staff member denied the allegation, stating that their protocol is to first check if a resident is okay and not in pain if a fall occurs. LPA interviewed three residents (R2-R4), and all three denied the allegation. On September 23, 2025, LPA attempted to interview the reporting party (RP) but was unable to do so, as RP no longer worked there and did not provide further information. On September 25, 2025, LPA also attempted to reach the resident's responsible party, leaving messages but receiving no response. LPA reviewed the facility's Unusual Incident Reports dated November 22, 2022, which indicated that the resident had been sitting or sometimes lying on the ground and refused to get up until hospice staff arrived and assisted. During the inspection, LPA observed that each resident had a hospital bed in their room. LPA was unable to interview the resident R1 because R1 left the facility on December 5, 2022, for a skilled Nursing Facility, and R1 passed away on December 27, 2022. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. Allegation #2: The Facility did not provide assistance to resident in a timely manner. The complaint alleged that the facility left R1 on the ground until the hospice nurse arrived after a fall on 11/15/2025 and 11/17/2025. On 09/25/2025, between 9:00 am and 11:30 am, the LPA interviewed the Licensee, who denied the allegation and stated that the staff offered to help the residents get to bed, but R1 refused On the same day and time, the LPA interviewed the Administrator (A1), who also denied the allegation and stated that the staff are trained to assist residents and maintain timely manners regardless of the circumstances. Additionally, on 09/25/2025, during the same time frame, the LPA interviewed the previous Administrator (A2), who denied the allegation. On September 25, 2025, between 9:00 and 11:30 AM, the LPA interviewed three staff members (S1, S2, and S3). All three denied the allegations and stated that when residents press the bell for assistance, it only takes a few seconds for staff to respond and enter the residents' rooms. On the same date, the LPA also interviewed three residents (R2, R3, and R4). All three residents denied the allegations and confirmed that they pressed the bell when they needed help, and the staff came and helped them very fast. On September 23, 2025, the LPA attempted to interview the reporting party (RP); however, the interview could not be conducted as the RP is no longer employed there, and no additional information was provided. On 09/25/2025, LPA attempted to interview the resident R1 responsible party; LPA left a voice message. On 09/23/2025, LPA reviewed the staff training on Personal Rights (Residents' rights, Visitors, Transportation, Personal Belongings, and Elder Abuse dated: 05/28/24). LPA was not able to interview the resident R1 because R1 left the facility on December 5, 2022, for a skilled Nursing Facility, and R1 passed away on December 27, 2022. Allegation #3: Staff refused medical equipment for resident. The complaint alleged that the staff denied residents access to necessary medical equipment, including a hospital bed, a fall mat, and an alarm mat. On September 25, 2025, between 9:00 AM and 11:30 AM, the Licensing Program Analyst (LPA) interviewed the Licensee, who denied the allegation. During the same time frame, the LPA also interviewed the Administrator (A1), who similarly denied the claim. A1 stated that every resident has access to either a full or half hospital bed with bed rails. Additionally, A1 mentioned that the facility has a fall mat and an alarm mat stored in the garage for use if a resident requires them. On September 25, 2025, between 9:00 AM and 11:30 AM, the LPA interviewed the previous Administrator (A2), who denied the allegations. During the same time frame, the LPA also interviewed three staff members (S1-S3), all of whom denied the allegations and stated that the facility is small. They mentioned that if a fall mat or an alarm mat is needed, they will assist in placing it inside the rooms. Additionally, on September 25, 2025, the LPA interviewed three residents (R2-R4), and all three denied the allegation. On September 23, 2025, the LPA attempted to interview the reporting party (RP) but was unable to do so as the RP is no longer employed, and no further information was provided. The LPA also attempted to reach the responsible party for resident R1, leaving a voice message. On September 23, 2025, the LPA reviewed the staff training on Personal Rights (covering residents' rights, visitors, transportation, personal belongings, and elder abuse), dated May 28, 2024. The LPA could not interview resident R1 because R1 left the facility for a skilled nursing facility on December 5, 2022, and sadly passed away on December 27, 2022. On September 25, 2025, the LPA observed a floor mat and an alarm mat in the garage. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the Administrator Daphne Drapeau.