complaint·May 29, 2025

During the investigation, the Department collected pertinent resident records, outside source records and conducted various interviews. According to details of the allegation, on or around November 26, 2024, R1 was not receiving the proper level of care which resulted in multiple falls and a fractured leg. Records collected revealed that R1 was diagnosed with a fractured leg prior to R1’s move into the facility and was actively receiving physical therapy for such injury from an outside source agency. Records also confirmed R1 was receiving medical care for pre-existing injury as early as October 11, 2024, only four days after moving in. Interviews with multiple staff confirmed that as of December 10, 2024, R1 had had a change in condition which had caused multiple falls, but no injuries were observed or reported. Interview with an outside source established that facility was providing multiple status check for R1 throughout the day. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove neglect/lack of supervision resulting in serious bodily injury. An exit interview was conducted with Executive Director Jonathan Wheeler , to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22 ) were provided.