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32 | On 01/28/26, LPA Sakinah Madyun conducted the initial complaint visit, and obtained copies of staff/resident rosters, five (5) staff files, including and In-Service Training Logs from June 2025 through November 2025 for staff #1-5 (S1-S5), and fifteen (15) residents files, including Physician Reports, Admission Agreements, Appraisal Needs and Services Plans, Identification and Emergency Information Face Sheets, Unusual Incident Reports, Medication Logs and Charting Notes from August 2025 through January 2026 for residents #1-#15 (R1-R15). Applications, Health Screenings, Warning Notices (Supervising Behavior Logs). LPA Madyun indicated that Administrator will email additional documents to LPA.
Regarding the allegation: Facility staff did not properly report an incident. It is alleged that facility staff do not properly report incidents, and alleges that R1 was involved in an incident and facility staff did not accurately report the incident.
Eight (8) out of eight (8) staff members stated that staff report incidents properly and accurately, and stated that staff receive training on how to report incidents. Nine (9) out ten (10) residents stated that staff report incidents involving residents and incidents are reported accurately. Administrator stated that the facility protocol for reporting incidents involving residents is for the care staff to report what occurred and what staff observed to Medication Technicians (Med Tech) or Licensed Vocational Nurse (LVN). Med Techs and/or the LVNs will document the incident, and the information is shared with Administrator, who then shares the information with any necessary parties. The Administrator states that staff are trained on how and when to report incidents as part of the staff’s initial training.
Regarding the incident involving R1, which occurred on 01/02/2026, Administrator states the incident was reported accurately. The report included the time and date that the incident occurred, and all persons involved in the incident and a description of the incident. Per Administrator, R1’s Responsible Party (RP) was contacted by phone within 24 hours after the incident occurred. S5 ,who directly observed the incident involving R1, stated that the incident was reported accurately. Interviews with R1 indicated that R1 was unsure if staff accurately reported R1’s incident to R1s Responsible Party. LPAs reviewed documentation that showed that Med Techs record observed incidents. LPA reviewed facility incident reports for the period, December 2025 through January 2026, and noted that the incident reports contained the essential components; time of incident, date of incident, description of incident and persons present during incident,
Continued on 9099-C
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