Complaint·December 11, 2025

(Cont. from LIC 9099) Regarding the allegation, staff consistently stated that Resident 1 (R1), who has a diagnosis of dementia, received consistent supervision throughout the day and night. Staff reported conducting frequent checks, particularly due to R1’s inability to use the call alarm system and increased ambulation associated with a recent urinary tract infection. Staff confirmed that R1’s authorized representative and medical provider were notified following the most recent fall, and that environmental adjustments, such as removing furniture and adding fall mats, were being discussed. Resident 2 (R2) stated that R1’s bedroom door was sometimes open and sometimes closed, and reported hearing about R1’s fall from staff. R2 had not witnessed any incidents but had observed staff interacting with and assisting R1. Outside Source 1 (OS1), R1’s authorized representative, stated that the facility promptly informed them of the fall and consistently communicates regarding R1’s care. OS1 stated that they were confident that the facility was doing its best to supervise R1 and had been responsive to concerns about room safety. Records reviewed included R1’s plan of care, resident appraisal, physician’s report (LIC 602), needs and services plan, emergency room documentation, communication records, staffing schedules, and rosters. These documents consistently described R1 as ambulatory, requiring one-person assistance with ADLs, and needing structured routines and supervision due to dementia and a history of UTIs. Records confirmed timely notification to R1’s authorized representative and adequate staffing levels during the relevant time period. The LIC 602, plan of care, needs and services plan, and other reviewed records provided consistent information and corroborated the staff, resident, and outside source interviews regarding the allegation. (Cont. on LIC 9099-C pg.2) (Cont. from LIC 9099-C pg. 1) LPA observed R1 ambulating throughout the facility and noted visible bruising and minor facial injuries. R1 demonstrated signs of confusion during the interaction. LPA observed R1’s bedroom, which contained multiple furniture items, including a large China cabinet. LPA advised the facility manager to consider fall risk mats in R1’s room. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Travonna Washington, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.