complaint·June 12, 2025

Regarding the allegation that due to insufficient and incompetent staff, residents are not provided adequate care and supervision: it was alleged that the facility is understaffed, residents in the memory care unit wander around causing issues with each other, residents have been observed fighting with each other, and residents are going to the bathroom in the rooms of other residents. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation. Per AD, there are 32 memory care residents, and the staff schedule provides for three caregivers and one medication technician plus a floating caregiver who covers both assisted living and memory care. LPA observed there were three caregivers and one medication technician in the memory care section as required by the staff schedule. LPA’s review of the facility’s payroll records and interview of the staff in charge of business matters corroborated that there are at least three staff in the memory care unit during all shifts. LPA reviewed the training records for five staff assigned to the memory care unit and confirmed that they are all properly trained. LPA interviewed 11 residents and did not obtain information corroborating the allegation. One staff interviewed stated that while facility staff do their best to address behaviors like wandering, aggression, and residents going to the bathroom in improper places, these behaviors are typical in a memory care setting and cannot be completely prevented. Although the behaviors alleged may be happening in the memory care unit, the information obtained did not corroborate that these behaviors are the result of insufficient or improperly trained staff. Regarding the allegation that resident sustained an unexplained injury while in care: it was alleged that, due to lack of care and supervision, R1 was hit by other residents on March 5, 2025 and on March 24, 2025 resulting in a black eye. LPA reviewed photographs of R1 showing R1’s black eye. LPA interviewed AD who stated that R1 is a new resident who is still adjusting to the facility, on March 5, 2025, R1 wandered into another resident’s room and R1 and the other resident hit each other, and there were no injuries from this incident. Regarding the incident on March 24, 2025, interviews with AD, staff, and a witness revealed that R1 sustained a black eye and a cut on their arm. However, no one witnessed this incident and AD and facility staff claim it was caused by R1’s hospice bath aide and not a resident or facility staff and the facility called the police and followed up with the hospice company multiple times but never received a response. LPA reviewed facility incident reports matching AD’s statements regarding the March 5, 2025, and March 24, 2025, incidents involving R1. LPA reviewed R1’s Physician’s Report dated April 11, 2025, which indicates R1 has Dementia. LPA reviewed R1’s Needs and Services Plan dated January 16, 2025, which does not address issues like wandering or aggression. However, review of R1’s Needs and Services Plan dated April 21, 2025, indicates that total assistance with wandering was added in response to R1’s altercation with another resident and that interventions included engaging R1 in activities throughout the day, adequate nutrition and hygiene, and supervision and awareness of R1’s whereabouts at all times. This shows that the facility reassessed R1 and added additional care to address R1’s wandering and aggressive behavior. Per a facility incident report, on June 10, 2025, R1 was involved in another altercation with a resident with no injuries. LPA interviewed PA who stated that in response to this recent incident, the facility will reassess both R1 and the other resident involved in the altercation, make any necessary changes to their care plans, and ensure the facility is able to meet their needs. Staff interviewed stated that while facility staff do their best to address behaviors like wandering and aggression, these behaviors are typical in a memory care setting and cannot be completely prevented. LPA interviewed 11 residents and did not obtain information corroborating any issues relating to safety. LPA’s review of the facility’s payroll records and interview of the staff in charge of business matters corroborated that the facility is following its staffing schedule. LPA reviewed the training records for five staff assigned to the memory care unit did not note any training issues. The information obtained did not corroborate that the incident on March 24, 2025 was caused by other residents or staff of the facility. Although R1 engaged in altercations on May 5, 2025, and June 10, 2025, with other residents, no serious injuries were sustained and the information obtained demonstrated that the facility is reassessing R1 in response to these incidents to ensure the facility is able to meet R1’s needs. The information obtained did not corroborate that the facility is unable to meet R1’s needs or that R1 sustained injuries due to lack of care and supervision. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.