complaint·March 18, 2026

was listed as a suicide attempt. Hospital narrative indicates R1 has a history of schizophrenia, depression, anxiety and history of suicide attempt by jumping . Resident was admitted to the hospital and subsequently admitted into a skilled nursing facility for rehabilitation. R1 did not return to the facility after the stay at skilled nursing. Interview with facility Administrator (AD) Monica Westphaln indicates the resident was evaluated and cleared by R1’s physician and Nurse Practitioner Psychiatrist for suitability for admission into the facility. R1’s physician confirmed evaluating the resident to ensure the resident was stable before signing off on admission. Per interview conducted, R1’s physician felt the facility was not to blame for R1’s suicide attempt as they do not believe R1’s behavior could have been predicted by the facility given they were deemed suitable for admission. During the investigation it was determined that while the facility utilizes video surveillance in common areas of the facility, the Administrator denied there was footage available. Interview with a facility staff member stated viewing the footage and observing nothing on the footage at that time. Facility staff interviewed confirmed status checks are done on residents every two hours. Four out of five staff interviewed stated that status checks were conducted on R1. Staff stated that R1 had been displaying unusual behavior prior to the fall and medication was being used to minimize their agitation and strange behaviors. A self reported incident report was submitted to the Department on October 3, 2024, indicating that R1 had been found on the floor after a fall with knee and hip pain. There were no further details included in the report. Two out of three staff and one witness confirm being told by facility staff or management that R1 had jumped off the balcony. One staff member indicated being told by Administrator to say R1 had fallen rather than jumped. Administrator denies the resident jumped off the balcony. Due to conflicting information, the Department is unable to corroborate the allegations Resident was neglected leading to hospitalization and facility failed to report incident. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator, and a copy of this report was provided to facility.