complaint·November 18, 2025

and bathing. Staff stated it was common for R1 to hit them during attempts to provide care. Review of facility progress notes for R1 corroborated these accounts, documenting multiple incidents of staff being hit and noting additional episodes of aggressive behavior toward other residents. Staff further reported that R1’s family expressed concerns about neglect due to R1 often being observed in bed. However, caregivers’ notes confirmed that R1 routinely did not sleep through the night and was awake for extended periods. Staff stated that R1 would become upset, irritable, or resistant in the mornings when care was provided and would often prefer to remain in bed. All staff interviewed reported that memory care staff provided the best care possible to meet R1’s needs, noting that R1 was a physically large, heavy, and tall individual who required extensive assistance. Staff reported that R1’s health was declining and that the family requested one-to-one care at all times, which facility staff could not provide due to responsibilities for other residents in the memory care unit. Review of R1’s evaluation and needs assessment indicated that R1 required the highest level of assistance with mobility and ambulation, including the assistance of two staff members. R1 also required total assistance with bathing, dressing, and toileting. One staff member reported that at times a third staff member was needed due to R1’s size and behaviors, but staff stated they continued to provide care to the best of their ability. It was alleged that facility staff are forcing resident to receive unnecessary services. Per a witness alleged that the facility threatened to require approval of medications for R1 or require the family to hire a private caregiver to meet R1’s care needs. Interviews with four out of six staff confirmed that R1 was a high fall risk and that their overall health was declining during their stay. Staff reported R1 would attempt to stand up from their wheelchair or bed without assistance, necessitating close supervision. Due to these safety risks, staff stated they recommended that the family consider a private caregiver to ensure continuous supervision. LPA reviewed R1’s medication records and Outside Agency Documentation, which showed that medication changes were initiated by R1’s family in consultation with R1’s Physician Assistant. Four out of six staff confirmed that the facility followed medical orders as prescribed. No evidence was found indicating the facility forced or manipulated medication decisions. LPA also reviewed R1’s billing records and resident ledger. Records did not show additional charges, or rate increases throughout the year, aside from a standard rent increase at the beginning of the new year. No unexplained or forced charges for private caregiving or additional services were noted. (Complaint investigation report continued on LIC9099C) Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.