complaint·November 18, 2025

R1’s Needs and service plan dated 8/30/2020 states R1 needs full assist with bathing, dressing and transferring. Care plan states R1 is a potential fall risk and requires two person assist. Care plan states R1 needs to be reminded to use walker and wheelchair. Facility incident reports dated 7/10/20, 7/11/20 and 1/12/21 state that resident had witnessed falls while being assisted by staff and family during transferring. Resident had two assessments conducted, one on 9/28/20 and 11/1/20. Resident Assessment Level of care remained at level 5 for both assessments. Based on staff interviews, Five staff members were interviewed regarding complaint allegations. one of five staff members (Staff 2) recalled that R1 was bed bound, difficult to transfer and needed total assist. S2 stated R1 used a wheelchair for support. Four of five staff members interviewed do not recall R1 and their level of care needed. Two of five staff interviewed (S4 & S6) stated that if a resident required a higher level of care, an assessment would be done especially if Resident needed a two person assist. Interview with witness 1 (W1) states that R1 is paralyzed and needs full assist. Based on conflicting information gathered the preponderance evidence has not been met deeming allegation resident requires a higher level of care to be UNSUBSTANTIATED meaning although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported. Regarding allegation responsible party placed a camera in residents room, LPA Tirre reviewed resident 1’s (R1) file and did not observe any photo waivers or camera release in facility records. One of five staff members (S2) interviewed stated they were aware of R1 but not aware of R1 having a camera inside facility apartment. Staff interviews stated that facility policy if resident has a camera in room, resident is to have a sign posted on door indicating camera and sign a waiver/ camera release which is placed inside residents file. Staff 2 did not recall a posted sign on R1’s door. Resident 1 lived at facility between 4/1/2020 and moved out 1/16/2021. Resident is no longer residing at facility. Based on information provided, allegation responsible party placed a camera in residents room, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED. CONTINUED ON 9099C Regarding the allegation Administrator is rude to residents and staff, Investigation revealed the following: Interview with Witness 1, stated that staff 1 (S1) was acting Administrator at time complaint was received and is very unprofessional and rude towards people. Per interviews with five staff members, five of five staff members do not recall S1. LPA Tirre reviewed S1’s employee records and did not observe any notes or write up’s for misconduct. According to Staff 4, S1 worked out of corporate office and assisted inside facility for temporary period of time till a new Administrator came on board. Based on information provided, allegation Administrator is rude to residents and staff, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegation is deemed UNSUBSTANTIATED An exit interview was conducted with Administrator Mike Marion and a copy of report was provided