complaint·April 20, 2026

continued from LIC9099 A review of the Admissions Agreement for Ivy Park at Rockville states, “Our residents are free to spend time unsupervised in their apartments…and are not under continuous one-on-one monitoring. As a result, falls…will occur from time to time and that if (signers of the Admissions Agreement) are not comfortable with this environment, we suggested you consider a higher level of care.” An interview with complainant on 12/19/2025 indicated that the complainant was unaware of the supervision requirements for R1, but thought the R1 was to be “checked in on, every hour” A review of a Service Plan sent to R1’s responsible party for signature by email on 11/03/2025 indicates in a Special Care Needs section of R1’s Service Plan that R1” requires status (wellness) checks-3-4x each (8 hour) shift due to recent hospitalization, illness, medication change”. This LPA notes that three to four wellness checks in an eight-hour shift would indicate a check every 2 hours to 2 hours and 40 minutes. An interview with staff (S1) indicates that “staff round on memory care residents every two hours but that residents are allowed to wander their units and be as independent as possible.” An interview with staff (S2) indicates memory care residents might get checked on as frequently as every 30 minutes, but that “every two hours is the normal basis” A separate interview of staff S4 indicates, that “residents would be checked on every 2 hours unless they were a hospice resident and then they would be checked on every hour.” A review of R1’s Physician Report reveals R1 was not on Hospice resident. Additional review of R1’s Service Plan indicates, "R1 is a fall risk....R1 prefers to wear adult briefs all day/night. And R1 will toilet themselves when the need arises”, the same care plan indicates that R1 is “shy and likes to keep to themselves, while an interview with S2 indicated that R1 “preferred to have their door closed at night to reduce light and noise” with S2 noting that when R1 wakes up at night they might be confused and begin to perform actions of their previous career which could cause confusion among other residents in the memory care unit. LPA conducted three staff interviews which revealed that R1 was checked on at least every two hours and when found fallen on the floor, timely medical service was provided. LPA obtained staff schedule which appeared to be sufficient to meet the needs of residents in care. LPA was unable to obtain information during the investigation to support that the facility did not have adequate staff. continued on LIC9099-C continued from LIC9099-C Interviews with care staff indicate that wellness checks of residents were not required to be documented by Ivy Park at Rockville and that only Unusual Incidents, like the Incident Report related to R1’s fall were required documentation. Review of Incident Report filled out by S3 indicates 911 was called after 4:45 AM and that the responsible party of R1 was notified by phone at 5:00 AM and that the Primary Care Physician (PCP) was notified by phone at 6:00AM. A note next to these notifications indicate, “left voice mail” Based on facility record review and staff interviews it appears that the allegation of staff did not provide adequate supervision of R1 is Unsubstantiated. A finding that a complaint is unsubstantiated means, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur This report was reviewed with Administrator Tedra Godfrey whose signature her denotes receipt.