complaint·March 9, 2026

Review of Resident 1’s (R1’s) medical and care assessment records dated 2021 revealed that R1 had mild cognitive impairment, was confused and disoriented, and required assistance with bathing, grooming, dressing, toileting and multiple safety checks per shift. While assessment records noted that R1 was not a fall risk, review of progress notes for R1 in 2021 revealed that R1 had multiple falls a month, usually with no injuries. Each time R1 fell, staff would assess R1 for any pain or injuries. Review of progress notes for R1 in 2021 revealed that in July 2021, R1 was found on the floor in a common area by staff and was observed to have minor injuries to the head and leg, and R1 complained of pain. Staff called 911 and emergency personnel assessed and transported R1 to the hospital. The Department was unable to obtain copies of R1’s discharge paperwork resulting in the Department’s inability to determine the severity of R1’s injuries. R1’s progress notes showed a pattern of staff conducting regular safety checks on R1, as well as encouraging R1 to attend communal meals and activities. Review of progress notes for residents revealed that an outside source complained that one staff working in the facility’s memory care was not sufficient to supervise residents overnight. Review of regulations regarding overnight supervision requirements for facilities caring for up to 100 residents revealed that at least one awake staff member was required to be on site with another staff on call and available to respond within 10 minutes. The Department was unable to interview any relevant staff that were working in 2021 or obtain staff schedules in 2021 to determine the staffing level in the facility’s memory care in 2021. However, interviews with staff responsible for oversight of the memory care in 2022 through 2024 revealed that the memory care was staffed with a minimum of 3 care staff during the morning and afternoon shifts, and a minimum of 2 care staff during the overnight shift. Those staff also stated that if a caregiver called out for a shift, other caregivers would be contacted to cover the shift, or the Memory Care Director would provide direct resident care. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).