Incident investigation·October 31, 2025

Licensing Program Analyst (LPA) De Leon conducted a case management -Incident visit to the facility above. LPA met with Diana Barnhill Licensee/Administrator of the facility and explained the purpose of the visit. LPA toured the facility and checked on the 10 residents in care. LPA requested the following records from the facility: Residents roster, Staff Roster, Staff Schedule for date of incident, copy of the video surveillance for 10/26/2025, 10 Residents care plans, Call pendants records for October 25th, 26th and 27th, and Copy of Staff 1 (S1)’s file for application, job description, mandated reporting, photo ID, CCL Clearance form, and training, as well as any remaining records not received from 10/27/2025 request. Licensee called LPA on Monday October 27, 2025, at 12:30pm to report an incident that happened on Sunday Oct. 26, 2025, around 1:30am-5:30am, Staff 1 (S1) on duty NOC caregiver text Licensee and Staff 2 (S2) that S1 was not feeling good and was leaving to go home. This text message was not read until after 5:15 am by S2, who immediately called the facility and got no answer called the Licensee, changed and headed over to the residence. The front door was found unlocked and all 10 Residents were found sleeping around 5:35am, Licensee arrived at 6:03pm and Staff 3 (S3) arrived before the start of S3’s 6am shift at 5:51am. The Licensee said company policy is for Staff to call and not to text when in an emergency. Continued 809-C LPA requested records from Licensee on 10/27/2025 after learning of the incident: Video Surveillance for 10/26/2025, Incident Report, SOC 341 sent to local law enforcement, Long Term Care Ombudsman (LTCO) and CCL. S1’s full name, address and phone number, call pendant calls for 10/26/2025 for all residents in care, list of residents that get up during the night and a list of residents that need toileting or briefs changes during the night, if S1 worked in the Licensee’s other facility, in which S1 did, Job description for Caregiver on NOC shift and a copy of S1’s texts to Licensee and S2. The Licensee sent the Incident Report on Monday October 27, 2025, at 1:34pm to Community Care Licensing (CCL) which provided additional details. S1 text message Licensee and S2 at 1:21am and after reviewing the video surveillance S1 left the facility at 1:23am. The residents were alone in the facility from 1:23am to around 5:39am when S2 arrived. Staff checked on residents, a few of them needed to be changed and had been left soiled and wet. The Licensee tried to call and Text S1 with no response and S1 was terminated on 10/27/2025 for the neglect of 10 residents in care by leaving them alone in the facility. S2 verified the text came into S2's phone at 1:23am and S2 did not hear the text message then upon waking read the message and immediately called the facility with no answer, then proceeded to get dressed and drove straight over to the facility and arrived at 5:39am, door was unlocked, checked residents in care and all 10 were accounted for and sleeping. S2 watched the video surveillance which showed Resident 1 (R1) had gotten up out of bed and set off the floor alarm and proceeded to the dining room around 1:23am, S1 had just walked out the door at this time video shows S1 turned around and came back into the facility and redirected R1 to R1's room, S1 proceeded to leave out the door again, front door unlocked and left the facility with 10 residents in care alone until 5:39am. S2 watched the full video and said no other residents got up from 1:30am- 5:39am when S2 arrived at the facility. Licensee watched the videos and confirmed the times of the incident. Continued 809-C LPA attempted to call S1 on 10/31/2025 at 8:49am the phone had restrictions set and would not accept LPA's call, LPA text on 10/31/2025 at 8:58am with a picture of business card and asking S1 to call LPA due to having restrictions set on phone was not able to call or leave a message. LPA attempted to call again on 10/31/2025 at 9:05am the phone number on file and was not able to get through due to restrictions being set on the phone number. LPA attempted 1 more call to S1's phone at 10:02am and the call would not go thorough. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.