Complaint·September 4, 2025

The incident occurred in the Memory Care Unit when R1 mistakenly entered another resident’s room, believing it was their own. The other resident struck R1, which resulted in the bruise. Documentation showed that facility staff immediately applied first aid and offered to transport R1 to urgent care, which R1 declined. Facility records indicate that R1’s primary physician was notified of the incident. Furthermore, staff relocated the other resident involved to a different apartment unit to prevent future incidents. Review of R1’s physician report states that R1 was able to communicate their needs and reported no pain when assessed. As to the allegations that staff do not ensure the facility is clean, orderly, and odor-free, LPA Haddadin conducted a facility walk-through, inspecting resident rooms, common areas, and restrooms. LPA did not observe any evidence supporting the allegations. Resident interviews confirmed that the facility did not have issues with cleanliness or odors of incontinence. LPA observed that each resident’s door displayed a housekeeping schedule indicating that rooms are cleaned twice a week, as well as upon request. Facility records included both a Janitorial Cleaning Schedule, which documents cleaning of common areas, and a Housekeeping Cleaning Schedule, which tracks resident rooms cleaned on assigned service days. Both record review and direct observations corroborated that cleaning protocols are in place and followed. Five of five staff interviews and five of five resident interviews denied the allegations. Based on the information obtained, the Department could not corroborate the allegations. While the allegations may have occurred or could be valid, there is not a preponderance of evidence to prove or disprove that the violations took place. Therefore, the allegations are determined to be Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility representative.