complaint·December 16, 2025

Outside source 1 (OS1) was interviewed and confirmed that the facility had communicated behavioral concerns and interventions with R1. OS1 stated that R1 has been having increased behaviors, and the facility staff have been meeting with OS1 with plans of moving R1 to the assisted living area of the facility. OS1 does not believe any resident entered R1's room or attempted any inappropriate behaviors with R1.Records review showed that the facility had documented behavioral plans, and a plan was in place to move R1 to a higher level of care. Records reviewed verified that R1 had a diagnosis of advanced Parkinson's, increased confusion, delusional thoughts, and paranoia. LPA observations confirmed that staffing ratios and supervision practices were in place and consistent with regulatory requirements. On 6/25/25, it was reported that the resident entered another resident’s room without permission and staff failed to prevent the invasion of privacy. Staff interviews revealed that staff were aware of the resident’s behavior and had implemented monitoring and redirection protocols. Staff interviews revealed that R2 was never seen entering R1's room at any time. Outside source interviews did not provide evidence that privacy rights were violated. Records review showed that the facility had policies in place regarding resident privacy, and staff followed procedures. LPA observations confirmed that room assignments and supervision were appropriate, and there were care plans in place to address R1's increased behaviors. On 6/25/25, it was alleged that staff actions contributed to a resident falling.Staff interviews indicated that the resident had a documented fall risk and staff were following the care plan. There were no recent falls documented or witnessed. OS1's interview confirmed that R1 had a history of falls due to medical conditions. OS1 and the facility staff plan of care was to move R1 to a higher level of care. The move to the assisted living area provided closer supervision. OS1 was supportive with the move from the independent living area to the assisted living area. Records review showed that fall prevention protocols were in place. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were given to Executive Director, Chris Neale.