complaint·November 14, 2025

... Continued from LIC 9099 breakfast and put R1 back to bed per R1’s request. Staff ( S2 )checked on R1 again at 10:00am and 11:30 am where R1 was still in bed. Around 12:00pm S2 checked on R1 again and R1 was then found lying on his buttocks with his back against the side of the bed. S2 called for assistance and S1 responded. R1 was asked if he had any pain in which he responded he did. 911 was called and R1 was taken to the hospital. R1 was not a known fall risk, there was no mitigation at the time to prevent any potential falls. Based on the information provided during the course of the investigation there is not enough corroborating evidence to show the allegation of Neglect/Lack of Supervision resulting in an injury to R1, as staff had seen R1 at 11:30 a.m. and found him on the floor between 12:00 pm., therefore, this allegation is deemed unsubstantiated. On the allegation: Staff does not ensure resident's toenails are maintained. S1 stated that when the family came to view the facility, they were given a packet and, in that packet, there was a podiatry authorization form regarding a Podiatrist. The form said W1, would perform podiatry services, and the private pay patients (which R1 was) would be charged $45.00.” S1 stated the family never returned that form, and since R1 takes blood thinners, his toenails have to be trimmed by a doctor not the facility. Based on the information provided during the course of the investigation there is not enough corroborating evidence to show the allegation of Staff does not ensure resident's toenails are maintained, as R1 was on blood thinners and which required his toenails to be cut carefully by a medical professional therefore, this allegation is deemed unsubstantiated. 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 allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.