complaint·November 18, 2025

the facility at the time of the alleged incident. All three residents stated they did not recall any residents sustaining an injury or experiencing a fall during that time. LPA Tea also interviewed two memory care staff members who were working during the period in question. Both staff members reported no knowledge or recollection of any resident sustaining an unexplained injury. Staff acknowledged that while falls are common among the residents’ population, they did not recall any specific incident matching the allegation. A previous LPA assigned to the complaint interviewed a former hospice staff member who provided care at the facility during the time of the alleged incident. The hospice staff reported they did not witness any injuries, falls, or inappropriate staff conduct. They stated they had never observed staff being rough or unkind to residents and described the allegation as a “he-said, she-said” situation without substantiating evidence. Based on LPA Tea’s observations, interviews conducted, and records reviewed, the allegation is determined to be UNFOUNDED. An unfounded finding indicates the allegation is false, could not have happened, and/or lacks a reasonable factual basis. 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.