complaint·March 23, 2026

It was alleged that Lack of staff supervision resulted in resident sustaining a head laceration. Records review and interviews revealed that R1 misjudged a hallway turn, struck a wall corner, fell backward, and sustained a head laceration. Staff were nearby and responded promptly, arranging EMS/ER evaluation. It was alleged that Lack of supervision resulted in resident being assaulted by another resident. Confidential witness reported a hallway altercation between R1 and R2. Staff intervened immediately and separated the residents. No injuries were reported. It was alleged that Staff neglect resulted in resident dehydration. Hospital records dated 12/24/2021 revealed that R1 was dehydrated during admission. Facility staff interviews reported frequent checks. However, the investigation did not obtain facility intake/hydration logs, ADL notes, weights/vitals, or care plan hydration parameters to link dehydration to facility neglect. It was alleged that Residents are not provided activities. Interviews revealed that the facility reported a centrally based activity program appropriate to memory care. The investigation did not obtain activity calendars, attendance logs, or resident interviews demonstrating a lack of activities. In the absence of contrary documentation, the allegation is unsubstantiated. Based on the information gathered, there is insufficient evidence to support the allegations mentioned above; Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore these allegations is UNSUBSTANTIATED. An exit interview was conducted with PATRICK MCADOO-MORTON and a copy of this report was provided.