Complaint·May 9, 2026

(continued from 9099) The investigation revealed. Allegation: Staff do not assist resident with obtaining medical care . It is alleged that R1 requires B12 injection and bed rails to prevent falls, and that it is not provided by staff. Also, that resident is having additional falls due to missing the B12 injections. LPA interviewed five (5) staff, and all five staff denied the allegation. LPA interviewed ten (10) residents and nine (9) of ten (10) residents could not corroborate the allegation. LPA attempted to contact R1 via phone at least six (6) times and left voice mail but did not get a return call. One staff member stated that there is no doctor’s order for B12 injections or bed rails which are required for facility staff to provide those. LPA reviewed resident’s order for B12, and the dose was lowered on 12/18/2026 from 1000mg tablet daily to every other day. One staff member stated that the tablet has the same effect unless the resident’s absorption is not good. There is no evidence that resident has absorption issues. One staff member stated that staff will follow up with the resident’s doctor to ask for B12 injection order to see if that has positive effect and reduce frequency of falls. The facility provided incident reports for two (2) falls total. There is insufficient evidence to support this allegation. Allegation: Staff do not ensure that resident's dietary needs are met. It is alleged that resident is unable to chew food properly and almost choked on some food recently. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed Ten (10) residents and nine (9) of ten (10) residents could not corroborate the allegation. There is currently a doctor’s order on file for mechanical/soft diet for R1 dated 07/28/2025. Dietary staff stated that order is being honored and that resident changes mind and can go back and forth on dietary wants. There is insufficient evidence to support this allegation. Allegation: Staff have not provided resident with reappraisal . It is alleged that facility has not conducted a reappraisal for resident since resident was admitted on 02/28/2025. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed Ten (10) residents and nine (9) of ten (10) residents could not corroborate the allegation. Records show that resident did not undergo a “significant change" in physical, cognitive, behavioral, or functional condition to warrant a reappraisal prior to 2/05/2026. Records reviewed show that a reappraisal for resident was conducted on 02/05/2026 and on 04/01/2026. Which is following Department Regulations. There is insufficient evidence to support this allegation. (continued on 9099C) (continued from 9099C) Based on interviews with staff and residents and records review, the information obtained during the investigation is insufficient to support the allegations. 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