Complaint·May 5, 2026

The investigation revealed the following: Allegation: Licensee is retaining a resident whose needs cannot be met The allegation alleges there is a resident who was improperly accepted in the facility’s Memory Care Unit, whose needs cannot be met due to an additional diagnosis of mental illness. During record review, LPA received and reviewed Resident R1’s Medical Assessment for Residential Care Facilities for the Elderly (dated 03/31/2025 & 03/18/2026), that indicates R1 was admitted to the facility with the initial diagnosis of Mild Cognitive Impairment (MCI). As of 03/18/2025 R1 has a dual diagnosis of MCI and a mental disorder. LPA observed on the Medical Assessments no aggressive behavior was indicated and no behavioral expressions indicated. LPA received and reviewed an Evaluation, through Tolwin Psychiatric Medical Group, conducted on 08/05/2025 that states staff reported R1 has not exhibited behavioral disturbances requiring intervention. Additionally, LPA received and reviewed a Follow-Up Evaluation, through Tolwin Psychiatric Medical Group, conducted on 04/07/2026 that states “no behavioral problems or safety concerns were reported. R1 remains directable though unpredictable at times.” Both reports indicate R1 was cooperative, guarded, and calm. LPA received and reviewed Resident Assessment/Service Plan, dated 04/05/2025, that indicates R1 may exhibit physically or verbally aggressive behavior and agitated or anxious behavior. Additionally, R1 may exhibit behaviors requiring staff intervention/redirection once per shift. During interviews with Staff S1-S6, were asked if they feel R1 requires a higher level of care, six (6) out of six (6) stated yes, after the past 6 weeks, they believe R1 requires a higher level of care. Additionally, during interviews with S1 and S2 stated they have been working with R1’s psychiatrist and case manager to find a more appropriate placement for R1. During interviews with Residents R2-R12, were asked if they have any concerns regarding them or a resident requiring a higher level of care, eleven (11) out of eleven (11) stated no, they have no concerns regarding a resident requiring a higher level of care. Allegations: Staff do not prevent resident from harming other residents The allegation alleges an ongoing risk from a resident who is attacking staff and other residents. During record review, LPA received and reviewed staff Orientation/In-Service Sign-In Sheets for Training staff received in June 2025 and November 2025. The topic for the training in June 2025 was Behavior + Interventions in Dementia and the topic for the November 2025 training was Behavior Management & Dementia. LPA received and reviewed Resident R1’s Medical Assessment for Residential Care Facilities for the Elderly (dated 03/31/2025 & 03/18/2026), that does not indicate Aggressive Behavior as a Behavioral Expression. LPA received and reviewed the RCFE Service Pan – Department & Shift Task Delegations (updated 04/03/2026) that indicates for Behavior Monitoring that staff on “all shifts” should “stop and watch” resident. During interviews with Staff S1-S6, were asked how they prevent and/or minimize altercations between residents, six (6) out of six (6) stated there is continuous supervision of residents in common areas, provide activities, and provide them space to calm down. During interviews with Residents R2-R12, were asked if staff have precautions in place to minimize and/or prevent altercations between residents, eleven (11) out of eleven (11) stated yes staff take precautions to prevent altercations. Additionally, Residents R2-R12 were asked if they feel safe living in this facility, eleven (11) out of eleven (11) stated yes, they feel safe living in this facility. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated . During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Linda Poythress, and a copy of this report was provided.