complaint·November 5, 2025

The investigation revealed the following: Allegation- Facility is not adhering to their plan of operation. The details of the complaint alleged that the facility is not adhering to their plan of operation by having a resident that may need a higher level of care. It was reported that the resident is residing in memory care and does not seem to be correctly placed, as they seem to suffer from psych related issues as opposed to age related memory loss. Consequently, it was reported that the residents in the memory care wing may be at risk, as they are not able to defend themselves. On 11/5/2025, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and resident (R1) regarding the allegation. 4 of 4 staff denied the allegation that Facility is not adhering to their plan of operation. All staff (S1-S4) stated they are adhering to their plan of operation and that R1 does not have a mental disorder diagnosis and is appropriately placed in the facility. Staff stated that R1 does not require 24-hour or skilled nursing care and is placed in memory care due to their physician’s diagnosis. Staff also stated that R1 has continued to take their medications as prescribed. The department interviewed resident (R1) about the allegation and the resident stated that they were happy with the care and supervision provided by the staff and that they did not have any problems with living at the facility. The department reviewed the Physician Report (Dated: 03/21/2025), Psychiatric Evaluation (Dated: 08/05/2025, 09/02/2025, 10/01/2025), Preplacement Appraisal Information (Dated: 04/1/2025), Appraisal & Needs Service Plan (Dated: 04/2025), and Unusual Incident Reports LIC624 (Dated:06/23/2025, 10/26/2025). The department did not observe in any of the medical documents that the resident may have been placed at the facility incorrectly. Additionally, the department did not observe that the resident has a psychiatric diagnosis and that the facility has regular psychiatric evaluations of the resident. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility is not adhering to their plan of operation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . No citations were issued. An exit interview was conducted with Brittany Kavanaugh, Executive Director, and a hard copy of this Complaint Investigation Report was provided.