Complaint·December 10, 2025

Allegation: Staff did not seek medical attention for resident’s change in condition. Based on records reviews, R1 was sent out on multiple occasions including May 8 th , May 17 th , May 19 th , and May 30th due to aggression and medication adjustments. 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 . Allegation: Staff did not notify authorized representative of resident's change in condition. Based on records reviews, on May 19 th family responsible party was notified of the incident via phone call, on May 21 st , and May 30 th family member either visited R1 or was notified by the facility of R1 behavior. In addition, responsible party signed updated changes of condition increased level of care from level one to level 2 on 5/21/25. 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 . Allegation: Staff did not ensure medications were dispensed as prescribed. Based on records review and interviews, medication A and B were administered as prescribed. R1 medication records indicated on May 7 th , 20 th, 21 st , 26 th , and 27 th, R1 either refused medications or R1 was out of the community with family, per records medications were dispensed as prescribed. 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 . Report continues on attached LIC9099-A