complaint·March 9, 2026

However, review of progress notes in 2022 and 2023 revealed that beginning in October 2022, R1 began experiencing visual hallucinations and was noted to be confused and disoriented. Outside source interviews provided supporting evidence that that R1 occasionally had hallucinations and had issues with short-term memory. R1 stated during interviews that they felt some staff were pleasant, however staff personalities determined if R1 felt comfortable with their care. Unfortunately, R1 did not provide clarifying details regarding the care provided by staff. Additionally, R1 did not provide any information or details to support the allegation that R1 sustained injuries from staff care. Outside sources were also unable to provide information regarding R1 sustaining any injuries, including one outside source who stated that they had not observed any bruising on R1. Interviews with other residents did not reveal concerns regarding the care provided by the staff at the facility. Interviews with staff did not reveal any evidence that R1 had any unexplained bruising or other marks and denied knowledge of any complaints regarding staff behaviors. 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).