Complaint·May 12, 2026

October and November, 2025, when R1 had incidents. R1 had a re-assessment of their care plan in October and November of 2025. Care plan was updated in October after R1 was noted with a change in condition in the community where 911 was called to assess the situation. R1 was sent to the hospital for further evaluation and was discharged back to the community with medication change and behavior mapping. Care plan was updated in November after R1 had a behavior episode that required 911 to be called and sent out for further evaluation. R1 returned to the facility and was placed on a 1:1 care. Interviews with 4 of 4 staff stated that it was first observed that R1 had a change of condition in October and November and a new care plan was assessed based on these changes. Staff stated that medication was handled as prescribed and had changes to medication from the incident in October and when R1 was admitted to hospice. Prior to those incidents R1 did not have an observed change of condition that needed to be addressed and/or needed medication changed due to a change of condition. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation are deemed Unsubstantiated. An exit interview was conducted with the facility representatives and a copy of this LIC9099 report was left at facility.