complaint·November 7, 2025

DR provided a splint/brace and R1s family declined to have surgery. Staff stated they never saw R1 fall only one time R1 slid out of his wheelchair and at that time R1 had no injuries. Staff did report R1 showed aggression and sometimes would hit the walls with R1s fists, but R1 never complained of any pain. Staff stated they did not see any swelling of R1s left wrist. The time and the date of injury could not be conclusively established as staff denied R1 had any falls while at the facility only the one time of sliding out of R1s wheelchair with no injuries. The cause of R1s fracture remains unknown and there is no evidence to prove the neglect/lack of care allegation. For the allegations of Facility was not sanitary and was in disrepair, the department conducted a visit on 8/7/2023 and found no evidence of immediate health and safety risks. Regarding the allegation of staff did not centrally store medication, all medications have proper logs for routine, PRN and controlled drugs. There were noted confirmations from med tech that the facility did receive medications for R1. For the allegation of facility did not maintain a comfortable temperature for residents, facility had scheduled maintenance checkup for air condition on 7/5/2023. A technician came to fix the air conditioner and was running during that time. Technician also came back on 7/19/2023 to fix another issue. Portable aircons were provided to residents’ rooms during this time. Regarding the allegation of Staff did not accord dignity to resident, staff members mentioned that they have not been rough with handling any resident nor have they seen other caregivers be rough with residents. Regarding the allegation of Staff were not able to communicate with residents, when the department conducted interviews to staff members, everyone was able to communicate and answer questions. Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and a copy is provided.