complaint·March 25, 2026

R1’s care reported no concerns and confirmed that R1 appeared well cared for and content. Records Review: No documentation indicated any incidents of mistreatment. R1’s LIC 602 showed no cognitive impairments and confirmed R1’s ability to make decisions. LPA Observations: R1 was observed to be well-groomed, alert, and oriented. The living environment was clean and organized, with no signs of neglect or mistreatment. On 7/2/24, it was alleged staff yell at a resident. Staff denied yelling at residents and described using calm, respectful communication. Residents, including R1, denied being yelled at or witnessing staff yelling at others. Outside Source Interviews, no reports or concerns were raised regarding staff yelling at residents. A review revealed no incident reports or documentation supported this allegation. LPA Observed observed staff interacting with residents in a calm and professional manner during the visit. On 7/2/24, it was alleged that staff inappropriately grabbed a resident. Staff denied any physical misconduct and described appropriate handling techniques. R1 and other residents denied being grabbed or witnessing inappropriate physical contact. Outside Source Interviews revealed no concerns regarding physical handling of residents. Records Review revealed no documentation or incident reports supported the allegation. LPA Observations: No signs of injury or distress were observed. R1 had no visible bruising or open areas. On 7/2/24, it was alleged staff are not properly feeding a resident staff Interviews reported that meals are served regularly and residents are offered adequate food and hydration. R1 and other residents confirmed that meals are satisfactory and food is available throughout the day. Outside sources confirmed that R1 has not expressed concerns about meals and appears well nourished. Records Review revealed no documentation indicated issues with nutrition or feeding. LPA Observations revealed R1 appeared well nourished and reported satisfaction with meals and food availability. On 7/2/24, it was alleged staff left a resident unattended. Staff reported regular monitoring of residents and confirmed that R1 is non ambulatory and in the memory unit but still checked on routinely. R1 stated that staff are consistently present and responsive. Other residents confirmed staff availability. Outside Source Interviews revealed no concerns were raised regarding residents being left unattended. Records Review revealed R1’s LIC 602 indicates independence in daily living activities and no need for constant supervision. LPA Observations revealed staff were present and engaged with residents during the visit. R1 was not observed to be unattended. On 7/2/24, it was alleged that a resident sustained unexplained injuries while in care. Staff denied any incidents involving unexplained injuries to R1 and reported that they bump into things while using the wheelchair and the staff attend to their bumps on their hands. Resident Interviews: R1 denied sustaining any injuries and reported no issues with care. Outside Source Interviews revealed no reports or concerns were raised regarding injuries. Records Review revealed bumps to R1's hands that needed bandages but no broken skin. LPA Observations revealed bandaged on R1 hands that were from bumping into the walls and the bumps were being monitored as needed. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, all allegations are UNSUBSTANTIATED. An exit interview was conducted with WesHebner, Executive Director], to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.