complaint·September 8, 2025

Interviews with outside sources, staff, and R1 and review of R1’s assessment records revealed that R1 had a diagnosis with major neurocognitive disease and had occasional verbal aggression and agitation. Interviews with staff and outside sources revealed that R1’s agitation often occurred when R1 was repositioned in bed for bathing or incontinence care due to a fear of falling. Additionally, staff stated that R1 would sometimes tell staff not to touch R1, and staff believed that it was due to R1’s pride and desire to maintain their independence. Interviews with staff and outside sources revealed that R1 would grab onto the bed rails while yelling, including when R1 yelled to prevent S1 from touching them, which supported staff and outside source beliefs that R1 was agitated due to a fear of falling. R1 denied any concerns regarding the care provided by the facility and the staff during interviews and stated that staff were nice to R1. Other residents denied any concerns with the facility and stated that staff are pleasant and responsive to care needs. The Department interviewed S1 who denied any inappropriate interactions with any residents, including R1. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Administrator John "Stuart" Neave , whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).