complaint·February 25, 2026

(Cont. from LIC 9099) Regarding the allegation that neglect resulted in a resident sustaining unexplained injuries, interviews did not corroborate the allegations. Interviews with facility staff and outside sources consistently described R1 as having fragile skin, a history of frequent falls, and episodes of combative and resistive behavior. Interviews stated that R1 was often combative during care, exhibited paranoia upon admission, and would swing their arms into objects, causing skin tears and often reopened previously dressed wounds. Staff reported that R1's hospice provider visited twice weekly to provide wound care, and both hospice and facility staff provided ongoing dressing changes throughout R1's time at the facility. Outside source interviews stated that R1 experienced multiple falls, and had skin tears that were not related to abuse or neglect but instead were consistent with R1’s condition and behaviors. Records review of R1's physician's report revealed that R1 had advanced dementia with recent significant progression and had a high fall risk. The report documented episodes of refusal of care, verbal aggression, and the need for fall-prevention measures. Records review of Hospice visit notes documented almost daily falls due to R1's difficulty rising from seated positions. Visit notes also documented ongoing paranoia and aggression, including an incident in which R1 struck a caregiver. No evidence supports that R1's injuries resulted from neglect. Injuries were consistent with the resident’s diagnosis, behaviors, fall history, and skin condition. Regarding the allegation that staff overdosed R1, interviews and records review did not support that staff over-medicated R1. Interviews reported that R1 exhibited significant anxiety, agitation, and aggressive behaviors, and that all medications were administered under hospice orders. Hospice ordered the facility to adjust dosages of R1's medication based on R1's response and any side effects. Interviews stated that R1 was prescribed Lorazepam for anxiety and shortness of breath, and that sedation and reduced activity were known side effects. (Cont. on LIC 9099-C pg. 1) (Cont. from LIC 9099-C) Records review of the Medication Administration Record showed that R1 received lorazepam on an as-needed basis, with no more than one administration per day, and often administered non-consecutively. The prescribed order instructed staff to administer one tablet every four hours as needed. Records review of R1's hospice visit notes revealed that hospice initiated trials of certain medications to address the resident’s significant agitation and anxiety, and dosages were adjusted accordingly when sedation or other side effects were observed. R1's responsible party requested that one trial medication be discontinued, and hospice discontinued the medication accordingly. No evidence corroborates concerns that staff administered medication inappropriately or beyond what was ordered. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director James Arp, whose signature below confirms receipt of these rights.