complaint·January 24, 2026

(continued from 9099) The investigation consisted of LPA taking a tour of facility, interviewing two (2) staff (S#1-#2), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, and R1 care plan. The investigation consisted of LPA taking a tour of facility, interviewing five (5) staff (S#1-#5), Six (6) residents (R#1- R#6), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, AR form, R1 care plan and other pertinent documentation related to the investigation. The investigation revealed: Regarding Allegation: Staff did not provide meals to resident. It is alleged that staff did not provide meals for resident one day. LPA interviewed five (5) staff and all five staff were aware that resident missed all three meals on 12/01/2025. Several staff stated that resident usually went to the dining hall on the fifth floor to eat meals. Culinary supervisor noticed she had not seen resident that day and asked another staff member if she knew about the resident.. The staff member answered with “resident is OK” and never checked on resident. Resident was receiving escorts to meals when she first arrived at the facility on care plan that was created on 06/19/2024. Effective 04/15/2025 an updated care plan was created and removed wellness checks and meal escorts to the dining room. The resident should have no expectation for staff to check on resident or to deliver a meal tray to resident’s room on this day according to the services agreed upon by the resident and facility on 04/15/2025. There is insufficient evidence to support this allegation. (continued) (continued) Allegation: Staff neglect/lack of supervision caused resident to remain on floor for at least 12 hours. It is alleged that staff neglected resident after a fall that resulted in resident being on the floor for twelve hours. Resident had wellness checks removed from care plan effective 04/15/2025. The resident was provided with a call pendant to press in case resident required assistance; however, resident did not press the pendant at any time during the time resident spent on the floor. According to the care plan effective 04/15/2025, the resident should have no expectation of a wellness check on 12/01/2026. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.