complaint·March 19, 2026

indicated that the other caregivers on duty at the time of the incident were assisting other residents and the med tech was in the medication room. Interviews with staff indicated that they were not short staffed and there was no lack in care or supervision at the facility. According to the staff schedule, the facility was fully staffed on the date of the incident. R1’s After Visit Summary and Progress Notes indicated that R1 returned to the facility from the hospital on November 19, 2025. There were no injuries reported and R1 had a change in their medication. According to R2’s Behavioral Expression Monitoring Log, R2 had incidents of aggressive behaviors towards other residents on October 27, 2025, October 28, 2025, and October 31, 2025 without injuries. The facility responded to the incidents by conducting a care conference with R2’s responsible party and reassessing them with the update in behaviors, which was signed on October 30, 2025. Between October 30, 2025 and November 12, 2025, the facility was in communication with R2’s physician and their responsible party to ensure they address R2’s changes in behaviors. The facility provided documentation indicating that R2’s physician had made adjustments to medications for behaviors as well as included antibiotics for Urinary Tract Infection (UTI). One medication utilized to reduce behaviors was increased on November 12, 2025 as well as another Urinalysis ordered for monitoring of UTI. Due to the November 16, 2025 incident, the facility immediately implemented one on one care to provide additional care and supervision for R2. The facility provided invoices indicating the dates of service from November 17, 2025-November 23, 2025. Based on interviews conducted and documentation obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.