complaint·January 13, 2026

9099C-1. Resident (R1) moved to the community in September 2023 with diagnosis of Dementia. (R1). The physician's report (LIC602) (completed on 7/22/2024) states that (R1's) primary diagnosis of Dementia is "longstanding, gradually worsening over time" and (R1) is needing some assistance with most ADL's. (R1) "has been on Memantine for some time" and "now with worsening behaviors has been throwing things at memory care, yelling, no clear triggers" but staff at the memory care state (R1) has "worse behaviors after (the family member) visits". The LIC602 notes (R1) has multiple secondary diagnoses, including Behavioral Change, Cataracts Bilateral, decreased vision in both eyes, and falls. The LIC602 also notes (R1) has aggressive and wandering behavior. Allegation: Staff does not provide adequate supervision resulting in resident falling and sustaining bruising. The allegation states that on 10/6/2025, resident (R1) was observed to have dark purple bruising on their neck and face which was sustained when (R1) fell while trying to rise from their seat at a table in the facility's dining room. (R1) was observed on 10/07/2025 and noted to have a swollen area above their left eye (on their eyebrow area ) that was purplish in color with bruising running down the left side of their face to the middle of her neck and photos were provided to the Department. The facility states that (R1) rose from their seat, tripped, fell and hit their face on the floor, but there was no explanation provided for the bruising to their neck. (R1’s) family member stated in October 2025 that they are at the facility regularly and for the past month, has been trying to tell the staff that (R1) is a fall risk. This family member stated they believe (R1) sustained bruises to the face and neck because staff, (S1), who works on the "pm" shift, did not provide supervision as she leaves the dining area and cannot be found. The administrator stated on 10/15/25 that (R1) "cries, yells and tries to hit staff" and confirmed an incident report was submitted was submitted to the Department on 10/2/2025 for a "witnessed fall" on 10/1/2025. The Administrator added that she was recently made aware that (R1’s) family member has been regularly visiting (R1) late, up until around midnight, and the visit will usually take place in the halls or TV area. The administrator stated these late visits have been "disrupting (R1’s) sleep pattern" and (R1) is "very tired" when woken up at 7:00 am for breakfast, stating that (R1) is only getting a maximum of (7) hours of sleep each day. The administrator explained that (R1) "wanders, cries and hits their head on the wall” as they miss their family member after the visit ends. *cont on 9099C-2.. 9099C-2 .. LPA and the Administrator discussed (R1) falling in the dining room on 10/1/2025 (11:47 am). The facility stated that there are a minimum of (3) staff who assist with serving residents all meals. On 10/14/25, (R1's) health care group advised that staff must assist (R1) with ambulating and the service plan has been updated accordingly. The administrator stated that on the lunch shift, a manager helps the kitchen staff serve meals and caregivers will rotate on who passes the food to residents. The administrator added that after the residents in the dining room are served, (1) staff will serve trays to residents in the rooms, and commented "not that many residents get lunch trays in their room- there are (7) total and stated it takes about (15) minutes. LPA asked the Administrator about what caused the bruising on (R1's) neck, and she stated she thinks it was "caused from the fall", commenting "it depends on (R1's) mood if they allows staff to assist". On 11/4/2025, the administrator stated that (R1s) family member is no longer visiting after 9 pm, when visiting hours end; however, (R1) "continues to fall" and was sent out on 11/3/2025, after having an unwitnessed ground level fall, returning the same day with diagnosis of hematuria. The administrator indicated that (R1) will be assessed 4x/shift and any change is to be reported to Primary Care Physician. Follow up appointment was on 11/4/25 - Seroquel 50 mg was discontinued but Seroquel 25 mg remained unchanged. Also discussed on 11/4/2025 was a prior unwitnessed fall on 10/29/25 (10:26 am) - Resident was crying extensively and exhibiting a behavioral expression, and was sent out for further medical evaluation due to complaining of neck pain. Discharge papers state the discharge diagnosis was a "fall and contusion of face" but does not mention neck pain. LPA reviewed the LIC624 submitted on 10/2/2025 for the fall on 10/1/2025. The LIC624 states that (R1) was "ambulating in the dining room, had a fall and landed on the floor hitting their face. (R1) was sent out for further medical evaluation and returned the same day with a diagnosis of "head trauma and periorbital hematoma of the left eye". Discharge papers confirm this discharge diagnosis. Charting notes document that on 10/1/2025 (11:47 am),(R1) fell while ambulating in the dining room, landing on the floor and hitting their face. (R1) was taken to a local hospital, and an injury was noted of a knot on the left eyebrow/forehead . Notes made on later on 10/1/2025 (3:13 pm) indicated (R1) would be returning to the facility later that day and there is “significant swelling by the left eye”; however, there was no internal bleeding, or new med changes and the CT scan is clear. *cont on 9099C-3... 9099C-3. . Notes made on subsequent days reflect that the “swelling is going down”; however, resident is still wandering around the facility with her eyes closed at times, and (R1) has been falling asleep during meals during the shift. Notes from 10/6/2025, document that (R1) became agitated and emotional on the NOC shift when their family member was trying to leave, and (R1) “kept getting up and wandering around” the community. Staff (S1) stated she began working at the community in May 2025, works on the "pm" shift from 3:00 pm- 11:00, and assists residents with supervision in the dining room. (S1) indicated she "never witnessed (R1) fall". Another staff stated (R1) has had a lot of falls and bruising as a result, and (R1) wanders around the community. This staff confirmed he has "never seen (R1) fall- but only after they fell", commenting (R1) is "very wobbly" . This staff added that he tries to calm her down as she "cries a lot". LPA asked how (R1) may have injured their neck as well as their face/nose when falling in early October 2025. This staff replied "I’m not sure how (R1) injured their neck- residents fall in different ways- we can't restrain them". LPA observed (R1) sitting in the dining room on 10/15/2025 (1:15 pm) and observed the left side of their face, above and below their eye, to be yellowish purple. LPA attempted to engage in conversation about how the bruising occurred, but (R1) could not explain it, and only commented “I think it hurts”. LPA observed (R1’s) eyes to be closed but then (R1) to slightly open them when LPA asked if they could open their eyes. On 10/15/2025, LPA spoke to a Med-Tech staff and caregiver staff who were also in the dining room at that time. The Med-Tech staff commented that she recently spoke to a representative at (R1’s) health care plan about the new Gabapentin prescription, which was prescribed as it "calms their nerves in pain and on their head". The Med-Tech stated (R1) is "not eating breakfast as (R1) is tired" in the morning and has "walked with their eyes closed and bumped into walls" on some mornings. The Med-Tech confirmed that (R1) has been "crying a lot, which has been normal lately". A care giver staff, stated that (R1) has been "screaming and walking into the walls" a lot lately. LPA reviewed an email sent on 10/11/2025 from the administrator to a representative at (R1's) health care group. The email states that (R1) has had a "change in condition- getting aggressive, crying yelling and swearing" two to three times daily, and staff need to stay with (R1) for at least an hour. *cont on 9099C-4. 9099C4. The email states that the facility will reach out to the health care group each time this issue occurs, medication changes have been made but the behaviors still continue. Finally, the email states that the facility thinks (R1) needs a higher level of care and to advise. The health care group responds by including the assigned representative to the email thread. On 11/5/2025, the facility administrator requests via email that a conference be scheduled with the family member also to discuss how to prevent any more falls, safety of resident, resident care and other topics. LPA was advised on 12/4/2025 by a hospice nurse that (R1) was placed on hospice services on 11/19/2025. The nurse indicated that Lorazapem and blood pressure medications have been stopped as they were making (R1) dizzy, contributing to falls. The nurse also stated that pain medications have increased and (R1) hasn't fallen since these medication changes. The facility reported (R1) to have passed later in December 2025. On 11/18/2025, the facility was cited for not ensuring facility staff provided the necessary interventions on 8/5/2025 when (R1) was running in the facility and later fell, sustaining a nasal bone fracture and laceration on the nose and lips, requiring stitches in the emergency room. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided.