complaint·April 7, 2026

worsening progressively, refusing to eat and discarding the meals. Progress report for R1 reflects that move in was January 1, 2024, and it was noted on May 11, 2024, resident had a behavior episode and responsible parties were notified. This reflects timeline of text messages. Interview with 2 of 2 staff stated that they would communicate with R1’s responsible parties since they were out of state. Staff stated that only change was with R1’s behavior episodes in which the nurse practitioner was notified, and changes were made with R1’s medication in aiding with resolving the behavior change. Staff stated that when responsible parties were notified their solution was to keep resident in their room to avoid interaction with others. It is alleged licensee does not ensure that resident (R1) is adequately fed while in care. Record review LIC602 physicians report reflect able to feed self as marked yes. Admission agreement reflects the basic services for R1, and no additional services were required. Services included memory care basic services include incontinence care, medication management, providing meals, bathing & dressing, escorting to and from activities and laundry service. Interview with 2 of 2 staff stated that R1 was able to feed themselves and did not require feeding. However, when R1 was noted to not want to eat staff would encourage R1 to eat and/or attempt to feed them. Staff would make various attempt to get R1 to eat but at times it was hard because they would refuse. R1’s responsible party would provide meals and/or groceries to help with R1 having food that they liked available in hopes that R1 would eat. Staff noticed that regardless of what food it was,when R1 did not want to eat they would refuse and flush food down the toilet causing the toilet to clog daily. It is alleged licensee did not ensure that staff addressed resident's (R1) change in condition in a timely manner. Record review progress report on May 11, 2024, is when it was first observed that R1’s behavior had changed. Text message to responsible party reflects that on May 11, 2024, staff S1 notified both responsible parties for R1 of the episode. Both records show timeline coincides with each other and reflect staff addressing the changes for R1. Progress notes reflect medication was changed on October of 2024 and R1’s appraisal and needs/services plan were updated for changes in November of 2024 which reflect the changes Continued on LIC9099-C in needs. Interview with 2 of 2 staff stated that once the behavior episodes became more frequent and more aggressive, they addressed the changes by notifying the nurse practitioner and medication was adjusted. Staff stated that once behavior became more frequent and unable to control medication was adjusted and R1 was reappraised for the changes. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is 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 with the facility representative and a copy of this LIC9099 report was left at facility.