Complaint·February 14, 2026

According to the complaint, R1 had been admitted to the hospital several times within the past year for various reasons, including falls and related injuries. Medical records reviewed revealed R1 has been diagnosed with a nervous system disorder resulting in an unstable gait, as well as other significant medical conditions. Documentation further identified R1 as generally independent but requiring staff assistance with certain activities of daily living (ADLs). Interviews with staff and documentation from medical professionals indicated R1 was advised to use assistive devices for mobility, which were provided by the facility. However, R1 was reported to be resistant to using assistive devices and selective in accepting staff assistance. Staff further reported that during a period of medication changes and other medical concerns, R1 exhibited behavioral changes that may have contributed to an increase in falls. Incident reports documented that R1 experienced un-witnessed falls resulting in injuries. However, facility records and medical documentation consistently reflected that R1’s falls were associated with documented medical conditions, including an unstable gait, neurological issues, and refusal to utilize assistive devices despite staff encouragement. Residents interviewed reported they were generally independent. While residents acknowledged that falls occurred, they stated that staff provided assistance when notified or contacted. Based on a review of facility and resident documentation, incident reports, medical records, and interviews with staff, there is insufficient evidence to prove that staff intentionally neglected R1, resulting in multiple falls and injuries. Therefore, the allegation is determined to be Unsubstantiated at this time. Allegation #2: It was alleged that staff failed to conduct a reassessment of Resident #1’s (R1) needs, resulting in neglect. To investigate the allegation, on 03/06/2025, from 12:30 p.m. to 2:30 p.m . , Licensing Program Analyst (LPA) Raymond Cromer conducted an initial complaint visit to gather evidence and obtain documentation related to the allegation. On 10/21/2025 and 12/23/2025, from 9:00 a.m. to 2:00 p.m . , LPA Tuesday Cabiness conducted subsequent visits to interview six (6) staff members and numerous residents. Additional documentation pertinent to the allegation was obtained and reviewed. (LIC9099C cont'd) Records reviewed revealed that R1 was admitted to the facility on 05/08/2023. Prior to admission, on 05/02/2023, facility staff conducted a pre-admission assessment and obtained medical records. Documentation reflected that R1 was diagnosed with a nervous system disorder resulting in an unstable gait, as well as other significant medical conditions. Documentation further revealed that on 04/09/2024, R1 was assessed for participation in the Assisted Living Waiver (ALW) Program through the Department of Health Services (DHS). A comprehensive assessment was conducted at that time to determine eligibility and level of care needs. R1 also received home health services during 2024. A follow-up reassessment was conducted with DHS on 10/11/2024. Records reviewed indicated that facility staff implemented and assisted with the care plan developed in coordination with DHS and home health providers. Documentation reflected ongoing monitoring of R1’s condition, including updates to needs and service plans, communication with R1’s primary care physician, documentation of health changes, and completion of incident reports as appropriate. Records further indicated that R1 experienced hospitalization's beginning in approximately October 2024 and again in early January 2025. Facility documentation reflected updates to R1’s medical records and continued monitoring of health status following hospitalization's. Based on the review of resident records, assessment documentation, care plans, physician communications, and interviews conducted with staff, there is insufficient evidence to support that facility staff failed to reassess R1’s needs or that neglect occurred as alleged. Therefore, the allegation is determined to be Unsubstantiated at this time. Exit interview and copy of report provided to staff.