Complaint Investigation Report

Interviews revealed that R1 did have an injury matching the description as alleged and that the injury showed up on approximately 2/17/2026. On 2/18/2026, the Administrator was made aware of R1’s injury by W1 and that the suspected cause was physical abuse from staff. W1 reminded the Administrator of the requirement to report this incident within twenty-four (24) hours to the proper agencies. Record review and additional interviews revealed that the facility submitted an incident report (LIC624) to Community Care Licensing Division (CCLD) on 2/24/2026, indicating R1 had a discoloration on their sternum that they stated was received from care staff and that R1 had also reported it to a med-tech days prior stating they had received it in the shower. The facility reported the suspected physical abuse of R1 to the Local Ombudsman office on 2/25/2026 via a written Report of Suspected Dependent Adult/Elder Abuse form (SOC341). Record review and interviews reveal the facility never reported it to local law enforcement. CCLD cross reported the alleged abuse to law enforcement. Interviews with the Administrator, Memory Care Director, and Regional Nurse revealed differing explanations for why the incident was not reported within the required time frame of two (2) hours verbally to law enforcement and twenty-four (24) hours in writing using form SOC341 to the long-term care ombudsman, law enforcement and CCLD. Despite these differing perspectives, all three individuals are mandated reporters and had sufficient information to ensure timely reporting. The delay therefore reflects a collective failure to fulfill mandated reporting obligations. The facility has since changed their reporting protocol to ensure reports are sent timely.

Based on all interviews conducted and documents obtained, the facility did not follow reporting protocols by taking over twenty-four (24) hours to report suspected elder abuse and never reported it to local law enforcement as required by law, at this time the above allegation was found to be substantiated , there is a preponderance of the evidence to prove that the alleged violation occurred.

On the allegations: staff caused injury to resident in care and staff handled resident in a rough manner while in care; it was alleged that Resident #1 (R1) was injured by three staff pulling and tugging on R1 while they assisted R1 with a shower on a day in February 2026 resulting in a raised swollen bruise on R1’s chest approximately three inches long by two inches wide. R1’s right arm also hurt due to the incident.