other·September 12, 2025

Review of R1’s medical assessment records dated January 17, 2025, revealed that R1 had a diagnosis of dementia with behavioral disturbances, was confused/disorientated, and did exhibit inappropriate, sundowning, and aggressive behaviors. Also, according to R1’s medical assessment they required assistance with All Activities of Daily Living (ADLs) except for feeding themself and were non-ambulatory with a wheelchair. Due to R1’s baseline memory loss they were unable to be used as a reliable historian to aid in this investigation. Interviews and records reviewed did not reveal that S1 handled R1 in a rough manner nor did it reveal that any other staff member had handled R1 in a rough manner. Internal and external interviews did not reveal that S1 had yelled at or spoken inappropriately to R1. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not handle residents with dignity and staff yelled at residents . Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Thomas, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.