Allegation: Staff did not report an incident as necessary.

It is being alleged that R1 was stabbed in the back with a pen by R3 and staff failed to report the incident. On 7/24/26, LPA Felisa Shirley observed an Unusual Incident Report dated 7/24/26 for an incident involving R1 on 7/18/26. LPA Felisa Shirley also observed and reviewed an Internal Resident Incident Report dated 7/18/26. Per Unusual Incident Report, on 7/18/26 the front desk was notified that R1 had a wound on their back which appeared to be a puncture wound. Upon review of the Internal Resident Incident Report, staff observed blood seeping through R1’s shirt and observed a long blood stain across the back of the shirt. On 7/24/26, LPA Shirley reviewed the surveillance video which contained R1 and R3 sitting at the table in the activities room. R1 was sitting drinking iced tea and R3 had an activity book. The surveillance video covered the time period from 5:30 pm through 7:33 pm and there was no indication of an assault or any involvement by another resident. At 7:33pm, the caregivers made contact with the resident and observed blood on R1’s shirt. LPA Shirley toured the facility on 7/24/26 and inspected R1’s room to locate the shirt R1 was wearing on the day of the incident. Upon examination, no holes or tears were observed in the shirt.

LPA interviewed staff 1 – staff 7 (S1 – S7). Of those interviewed 4 out of 7 denied the allegation. Three staff did not know if incident was reported. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 0 out of 5 denied the allegation. Four residents didn’t know if incident was reported and 1 resident did not answer.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not report an incident as necessary,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Executive Director, Ace Huynh.