Complaint·February 5, 2026

(continued from LIC 9099) Review R1's Physician’s Report dated November 11, 2024, revealed diagnoses of Mild Cognitive Impairment (MCI) and Major Depressive Disorder (MDD), along with a history of traumatic subdural hemorrhage. The Physician’s Report does not include a dementia diagnosis. Review of R1's Care Service Plan assessed on June 1, 2025, and effective June 22, 2025, revealed the resident is non-ambulatory, requiring two-person assist for transfers, frequent hands-on assistance with toileting and dressing, total assistance with showers, drainage bag management four times daily, and medication management. The plan also notes high fall risk and behavioral refusals of care. Interviews with staff revealed they did not confirm being instructed by S1 to omit or delay documentation related to changes of condition. However, an interview with an outside source revealed S1 accompanied R1 and two outside sources to R1's physician appointment. The outside source reported that during this visit, S1 had a private discussion with the attending physician outside the room. The outside source could not confirm the content of that discussion. The Department has investigated the above-mentioned allegation and based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with General Manager Jill Johnson, whose signature below confirms receipt of a copy of this report, LIC811 Confidential Names list, and the Licensee Appeal Rights (LIC9058 03/22).