complaint·October 17, 2025

(Continued from LIC 9099) It was alleged that the: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition and Staff refused to seek medical attention for resident. LPA reviewed Unusual Incident Reports for R1 from 3/07/2022, 3/30/2022 and 04/05/2022. On 3/7/2022 R1 shoved Resident #2 (R2) in the hallway near the theater. R2 also had a diagnosis of dementia, It was documented and Power of Attorney (POA) was notified. In the report it stated POA would notify physician regarding aggressive behavior. On 3/30/2022 R1 had another incident with R2 in the dining room; hitting R2 with a book. 9-1-1 was notified and R1 and R2 were transported to the Emergency Room for further assessment. POA for R1 was notified and the facility Health Services Director (HSD) faxed physician of R1's continued behavior. On 4/05/2022 a third incident occurred where R1 pushed R2 to the ground. 9-1-1 was called and fire department and paramedics arrived. Police officers also responded and gathered witness statements. R1's POA was notified. In the incident report it is documented that R2 never provoked R1, and that a family conference was requested. On 4/06/22 R1's POA picked up resident and brought R1 to the hospital for a psychiatric evaluation. R1 did not return to the facility. After the first incident on 3/7/2025, the resident returned with new medications. The Executive Director spoke directly to the POA regarding a personal companion and requested an evaluation with a neurologist regarding behaviors to conduct a re-appraisal of R1's change of condition. HSD stated the POA never took R1 for assessment and that a statement made by POA made HSD realize R1 had a history of physical aggression that was not disclosed per Physician's Report. Medical Technicians (MedTechs) continued to communicate with the Primary Care Physician (PCP), per incident report and HSD interview, regarding R1's behavior. Per HSD interview, R1 did not sustain injuries and that is was R2 who sustained injuries due to R1's behaviors. The allegations that: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition and Staff refused to seek medical attention for resident are Unsubstantiated. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) It was alleged that: Resident's shower bench is in disrepair, Staff did not meet resident's laundry needs, Resident's bathroom is dirty and Resident's rugs are dirty. LPA reviewed housekeeping schedules. There are six housekeepers with two assigned to Memory Care. Housekeeping and laundry are scheduled seven days per week. Each housekeeper has a daily housekeeping inspection form; which include checking off if vinyl/carpet and shower/tub/ fixtures are in working order. Comments are written on the daily inspection list for follow-up such as: laundry to be done. LPA interviewed five of five staff members and the current Maintenance Director regarding housekeeping and laundry. Four of the five staff members were working during the time period of the incident. Per interviews, staff members stated resident bathrooms were cleaned and maintained since the Memory Care residents were encouraged to be in the common areas for socialization and activities, as well as dining. Housekeepers stated that in 2022 there were not a lot of memory care residents so it was easier to maintain resident rooms. LPA asked if any of the staff recalled the condition of R1's bathroom or laundry. Staff recalled the resident but stated if there was a broken shower chair, dirty rugs, an unclean bathroom or laundry that needed to be done, that it would have been noted and cleaned. None of the staff members interviewed remembered if R1's laundry was not cleaned since it was almost three years ago. LPAs Fred Arias and Rose Ruppert toured the Memory Care unit on December 30, 2024 and entered three random resident bathrooms while residents were at lunch. All bathrooms were clean and in working order. An interview with the Maintenance Director stated that Memory Care is usually clean and repairs are handled promptly. On 2/11/2025 LPA toured the laundry room and interviewed housekeeping and care staff regarding laundering procedures Housekeeping staff clean bedsheet linens and towels once a week per schedule; or as needed. Care staff cleaned residents' personal belongings once a week, or as needed. Thus the allegations that the: Resident's shower bench is in disrepair, Staff did not meet resident's laundry needs, Resident's bathroom is dirty and Resident's rugs are dirty are Unsubstantiated. (Continued on LIC 9099-C2) (Continued from LIC 9099-C1) It was alleged that Staff did not shower resident Per Physician's Report dated 09/09/2021, R1 had the capacity for self care which included: bathing, dressing/ grooming, feeding self and being able to care for toileting needs. Interview with the HSD stated staff did not shower R1 but would remind R1 to take a shower. Staff could not force R1 to shower if resident refused. This allegation is Unsubstantiated. Based on LPA record review, observations and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations that the: Resident sustained injuries while in care, Staff did not properly assess resident's change in condition, Staff refused to seek medical attention for resident, Resident's shower bench is in disrepair, Staff did not meet resident's laundry needs, Resident's bathroom is dirty, Resident's rugs are dirty, and Staff did not shower resident are Unsubstantiated. An exit interview was conducted with Peggy Ulland, Executive Director and a copy of this report and LIC 811 was provided to the facility.