Complaint·April 23, 2026

the emergency call system, staff responded promptly, and (R1) was transported to the hospital. (R1) was initially treated and returned to the facility; however, after reporting continued pain, (R1) was later diagnosed with a fractured humerus during a subsequent hospital visit. Following the second hospitalization, the facility reassessed (R1) and updated the service plan to include a higher level of care. Staff reported that prior to the fall, (R1) was independent and did not require supervision. After the incident, staff provided increased assistance, including regular checks and escorting. (R1) confirmed staff check on them periodically. Interviews by other residents identified as independent; not needing assistance from staff or using the emergency alarm. Based on interviews and records reviewed, LPA determined (R1) did not require supervision prior to the fall, and the facility implemented appropriate interventions following the injury. Therefore, there is insufficient evidence to support the allegation. The allegation is deemed Unsubstantiated. Allegation # 2: I t was alle ged that facility staff speak to residents in an inappropriate manner. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., during the initial complaint visit, LPA interviewed six (6) out of (6) staff. LPA also obtained and reviewed resident and facility documentation. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) out of twenty-one (21) residents, including Resident #1 (R1). According to the complaint, the reporting party (RP) alleged that (R1) was being verbally belittled and humiliated by staff. However, during interviews conducted, including with R1, residents reported that staff are respectful and not rude. Residents further reported that staff are caring, provide appropriate care, and that they have not observed any instances of staff belittling or humiliating residents, including R1. Staff denied mistreating or humiliating residents and reported that they treat residents with respect and work diligently to provide quality care. LPA attempted to contact the reporting party (RP) and other potential witnesses on multiple occasions but was unsuccessful. Based on interviews conducted with R1, other residents, and staff, there is insufficient evidence to support the allegation that staff speak to residents in an inappropriate manner. Therefore, the allegation is determined to be Unsubstantiated at this time. (See LIC9099C Allegation #3: It was alleged that staff do not ensure residents are provided prescribed medication. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., during the initial complaint visit, LPA interviewed staff and six (6) out of six (6) residents. LPA also obtained and reviewed resident and facility documentation. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) out of twenty-one (21) residents, and resident #1 (R1). LPA also audited and inspected residents’ medications and medication administration records (MARs), including those for R1. According to the complaint, it was alleged that R1 missed morning medication. However, records reviewed for R1 revealed that R1 was admitted to the facility on 07/31/2024, and medication management was not initially provided by the facility. Documentation indicated that R1 was authorized by their primary physician to store and self administer their own medication. The facility did not begin providing medication management services for R1 until September 2025. The alleged missed medication was not specifically identified or documented. Records reviewed after the facility began providing medication management indicate that medications were administered in accordance with physician’s orders. Interviews conducted with residents revealed that they have not missed medications administered by staff. Additionally, several residents reported that they independently store and self administer their own medications without staff assistance. R1 reported to LPA that they have not missed any medication administered by staff. Based on record review and interviews conducted, there is insufficient evidence to support the allegation that staff failed to ensure residents receive prescribed medication. Therefore, the allegation is determined to be Unsubstantiated at this time. Allegation #4: It was alleged that staff do not treat residents with dignity and respect. To investigate the allegation, on 09/04/2025, from 10:30 a.m. to 12:30 p.m., during the initial complaint visit, LPA interviewed six (6) out of six (6) staff. LPA also obtained and reviewed resident and facility documentation. On 03/10/2026, from 10:30 a.m. to 2:00 p.m., LPA conducted a subsequent visit and interviewed twenty-one (21) out of twenty-one (21) residents, and Resident #1 (R1). (See LIC9099C) According to the complaint, the reporting party (RP) alleged that R1 was not being treated with dignity and respect. Contrary to the allegation, during interviews conducted, including with R1, residents reported that staff are respectful and treat them with dignity. Residents further reported that staff are caring, provide appropriate care, and that they have not observed any instances of staff treating residents without dignity and respect, including R1. Staff denied the allegation and reported that they treat residents with respect and work diligently to provide quality care. LPA attempted to contact the reporting party (RP) and other potential witnesses on multiple occasions but was unsuccessful. Based on interviews conducted with R1, other residents, and staff, there is insufficient evidence to support the allegation that staff do not treat residents with dignity and respect. Therefore, the allegation is determined to be Unsubstantiated at this time. Exit interview conducted and copy of report provided to Administrator.