Complaint Investigation Report

During today’s visit, LPAs conducted a health and safety check tour of the facility at 11:19 A.M. During the walk-through, LPAs observed deficiencies unrelated to the complaint allegations, which will be addressed in a case management report. Throughout the course of the investigation, LPA Conway reviewed all documents previously obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined:

Regarding the allegation “Licensee did not comply with reporting requirements”, it was alleged that facility staff and the ED selectively report incidents to Community Care Licensing (CCL) and that serious falls and injuries are not consistently reported. Interviews with the ED revealed that the facility utilizes an internal incident reporting form completed by staff when an incident occurs. Once completed the report is submitted to the ED, who then determines whether the incident is reportable to CCL. Based on documentation and prior communication, on 4/15/2025, LPA Conway emailed the ED a reminder that incident reports must be submitted to the licensing agency, the Primary Care Physician (PCP), and the resident’s responsible party within seven (7) days of the occurrence, pursuant to Title 22 regulations. During prior visit and prior to this complaint, LPAs Conway and Dulek informed the ED that all incidents, regardless of perceived severity, must be reported to CCL. The ED acknowledged the reporting expectations and explained that while efforts are made to notify appropriate parties, the ED manages a heavy workload. However, further investigation and interviews with credible witnesses revealed that a reportable incident involving two residents, which occurred in March 2025, was not disclosed by the facility to the residents’ PCPs, hospice agencies, and/or responsible party. Instead, some of those parties became aware of the incident through contact initiated by hospital staff. Additionally, in May 2025, another resident was hospitalized, and once again, no formal notification, either verbal or written, was provided by the facility staff to the resident’s responsible party. The RP learned of the hospitalization only after being contacted directly by the hospital. Staff interviews confirmed that facility staff are not responsible for submitting incident reports directly to CCL. Instead, internal incident reports are reviewed solely by the ED, who decides whether to complete and submit a formal incident report form (LIC 624) to CCL and which are not, raising concerns about consistency and compliance in the facility’s reporting practices. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time.