complaint·April 24, 2025

Page 2 Allegation: Resident (R1) sustained unexplained bruising while in care. R1's family member (FM) stated that on 5/10/22, FM reached out to the assistant director regarding an incident where R1 ended up crying at the end of R1's shower and the next day the nurse found bruising on R1's shoulder and arms. LPA reviewed the documents from Pine Park Health, a third party that provides medical services to the residents in the facility. Pine Park's records and visit notes for R1 from 1/26/22 to 6/22/22 didn't show any note indicating R1 had bruising. Facility's Narrative Charting of communication with R1's responsible person and R2 (R1's husband) for R1 for 1/10/22, 1/13/22, 1/29/22, 2/16/22, 2/22/22, 3/14/22, 3/30/22 and 6/15/22 had no information pertaining to bruising. There's no UIR regarding bruising. LPA could not interview R1 and R2 since they were longer at the facility. Based on information gathered and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. Allegation: Residents not provided a pendant. FM stated that R1 and R2 did not have pendant for 4 days because it was broken. S1 and S2 stated R1 and R2 had pendant. S1 stated she does not recall R1 and R2 not having pendant for days. S2 stated it's always R2 who pressed the pendant when help was needed. S3 and S4 stated the residents in Assisted Living (AL) are provided pendants but not the residents in Memory Care (MC). When pendant is not working or broken, it is replaced same day. These statements were confirmed by LPA with ED. ED stated only residents in AL are provided pendant. ED further stated that residents in MC are not given pendants because staff do more supervision. If the pendant is broken, it is replaced the same day. The facility has at least 6 extra pendants. .....continued on 9099C (page 3) Page 3 R3 and R4 stated they have pendants. R3 stated she seldom use hers while R4 stated the pendant is working and the staff check it regularly. Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. Allegation: Facility does not have an administrator during hours of operation. When LPA conducted an initial complaint visit on 6/24/22, LPA met with interim Administrator Mandy Taylor. Ms. Taylor has valid administrator certificate. S1 stated never was a time where facility has no executive director (ED)/administrator. If the ED quits and the corporate is in the process of hiring, the Regional Director serves as interim administrator. S2 stated the facility has always administrator to talk to. R3 and R4 stated there's always administrator and staff available. Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.