Complaint Investigation Report

Allegation #1: Staff did not seek timely medical attention for a resident.

The complaint alleged that the resident was physically attacked by another resident and called for help, but the staff did not take R1 to the hospital. On 10/24/2025, LPA Richard reviewed the interview records from the previous LPA Gardner with Resident #1 (R1). R1 was screaming that another resident slapped R1 and didn’t leave any marks, and no injuries, and R1 didn’t want to go to the hospital . On 10/24/2025, LPA Richard reviewed the interview records of the previous LPA with the Administrator (A1), who stated that after the incident occurred, staff notified the physician and moved the resident out of the area. On 10/24/2025, LPA Richard reviewed R1’s Physician Report LIC602A dated 06/17/2021, which s howed that R1 has suffered from cognitive impairment. On 10/24/2025, LPA reviewed the interview records of the previous LPA Gardner with the Administrator, who stated that after the attack occurred, staff notified the physician and moved the resident out of the area. LPA Richard was unable to review any pertinent documents requested by the previous LPA Gardener. No residents were available for interview. Due to the facility being closed, no further information is available to LPA Richard. Therefore, the LPA was not able to complete a full investigation.

Based on the limited information gathered, LPA finds that although the allegation may have occurred or be valid, there is insufficient evidence to determine whether the alleged violation occurred; therefore, the allegation is Unsubstantiated.

Allegation #2: Staff did not respond to a resident’s alert.

The complaint alleged that R1 called for help, the resident came to assist, but there was no follow-up after the attack. On 10/24/2025, LPA Richard reviewed the interview record from the previous LPA Gardner with resident #1 (R1). There were no injuries, no marks, and R1 refused to go to the hospital. On 10/24/2025, LPA Richard reviewed the interview records of the previous LPA with the Administrator (A1), who stated that after the incident, staff notified the physician and moved the resident out of the area. LPA Richard was unable to review any pertinent documents requested by the previous LPA.