Complaint·December 23, 2025

LPA also obtained and reviewed additional documentation pertinent to the allegation. According to the complaint, R1 requests wine during evening meals, which may have caused R1 to fall and remain on the floor overnight until the following morning. Interviews with staff reported R1 may have a drinking problem and are permitted to consume wine served during dinner. Staff stated R1 is independent and that the facility cannot force R1 to stop drinking. It was further reported that R1 orders wine independently and that friends bring wine during visits. LPA interviewed R1, who denied remaining on the floor overnight until the following morning. R1 reported wine is served at dinner and that R1 consumes it but denied having a drinking problem and denied that alcohol consumption caused any falls in R1’s room. Interviews with residents indicated the facility serves alcohol and allows residents to drink at their discretion. Residents reported observing other residents consuming excessive amounts of alcohol but stated it was not their concern. Based on interviews conducted and observations made, there is insufficient evidence to substantiate that facility staff failed to prevent a resident from engaging in self-harm. Therefore, the allegation is Unsubstantiated at this time. Allegation #2: It was alleged that facility staff did not address a resident’s change in medical condition. To investigate the allegation, on 01/23/2025, from 10:30 a.m. to 3:30 p.m . , (LPA) Raymond Cromer conducted an initial complaint visit to gather evidence and obtain facility documentation and resident records related to the allegation. On 05/12/2025, from 12:00 p.m. to 2:00 p.m., LPA Cromer conducted a subsequent visit to obtain additional information. On 09/22/2025, from 10:20 a.m. to 2:15 p.m . , LPA Tuesday Cabiness conducted an additional visit, during which interviews were conducted with four (4) staff members, Resident #1 (R1), nine (9) residents out of ninety-five (95 ) , and other witnesses involved with the complaint. LPA also obtained and reviewed resident records, and facility documents pertinent to the allegation. Information obtained through interviews indicated that R1 experienced multiple falls and had bathing and hygiene issues. It was reported these factors contributed to wounds on R1’s leg. Review of R1’s home health records revealed that R1 has chronic venous ulcers and received treatment for the wounds from May 2024 through September 2025. Review of facility documentation regarding R1’s medical condition revealed that In November 2024, an updated resident service plan was implemented documenting that R1 was independent, did not require assistance with activities of daily living (ADLs), and was receiving home health services for treatment of wounds on R1’s legs related to R1’s medical condition. ( Cont'd LIC9099C) In January 2025, R1 experienced a fall and was having pain in R1’s legs, which caused R1 to be hospitalized, after which R1 was admitted to a skilled nursing facility and did not return to the facility until March 2025. Upon R1’s return, a new physician’s report was completed. In April 2025, the facility updated R1’s assessment plan to reflect the significant changes in R1’s health condition. Based on the information obtained, LPA determined the facility addressed R1’s change in medical condition by completing updated assessments and maintaining a current physician report. Therefore, there is insufficient evidence to support the allegation that the facility failed to address R1’s change in medical condition. The allegation is deemed to be Unsubstantiated at this time. Allegation #3 : It was alleged that resident developed multiple pressure injuries while in care. To investigate the allegation, on 01/23/2025, from 10:30 a.m. to 3:30 p.m . , (LPA) Raymond Cromer conducted an initial complaint visit to gather evidence and obtain facility documentation and resident records related to the allegation. On 05/12/2025, from 12:00 p.m. to 2:00 p.m., LPA Cromer conducted a subsequent visit to obtain additional information. On 09/22/2025, from 10:20 a.m. to 2:15 p.m . , LPA Tuesday Cabiness conducted an additional visit, during which interviews were conducted with four (4) staff members, Resident #1 (R1), nine (9) residents out of ninety-five (95), and other witnesses involved with the complaint. LPA also obtained and reviewed resident records, and facility documents pertinent to the allegation. Based on interviews and documentation reviewed, R1 was reported to be prone to falls due to slipping from the wheelchair. It was further reported that R1 experienced difficulty transferring from the bed, which caused pain in R1’s legs and impaired R1’s ability to stand. Review of R1’s medical history and documented decline in health revealed that R1 has chronic venous ulcers. Records indicated R1 received home health services for wound care from May 2024 through September 2025 due to wounds on the body. During an interview with LPA, R1 reported that the wounds were caused by the wheelchair. R1 further reported that both home health providers and facility staff provided medical treatment and assistance to support healing of the wounds. (Cont'd LIC9099C) Documentation reviewed also indicated that R1 was admitted to a skilled nursing facility for several weeks due to R1’s declining health condition, wounds, and inability to stand. Based on interviews and documentation reviewed, there is insufficient evidence to support the allegation that R1 developed pressure injuries while in care. The allegation is determined to be Unsubstantiated at this time. Exit interview conducted, and copy of report provided to Director of Residential Care Services.