R4 was interviewed during an unannounced facility visit. R4 denied that the facility did not provide adequate supervision for residents and informed that the incident they and R3 were involved in was a miscommunication, as it had not been established that they were unable to leave the facility without staff supervision. R4 informed that staff cared for them well and that they felt safe at the facility. R3 was unable to be interviewed due to passing away. R1 and R2 were unable to be interviewed due to no longer living at the facility.

Two Outside Sources (OS1, OS2) were interviewed regarding the allegation. OS1, a prominent Geriatric Specialist in the county, provided training to facility caregivers on 12/15/2025 regarding caring for residents with Parkinson's Disease. OS1 informed that they provided a 40-minute training with a 20-minute Q&A session at the facility and the staff were engaged and asked good questions. OS1 stated that the facility's training to staff for residents with Parkinson's Disease was better than most in the county, and OS1 regularly recommended the facility to people with some of the highest care needs among this population. OS1 additionally stated that depending on the level of severity of the condition, the RCFE training regulations for Dementia care covered similar care needs for residents with Parkinson's. OS1 stated that the facility's care model went above the requirements, as they provided a licensed medical professional on staff 24-hours per day and the facility's caregiver training was more extensive than other facilities. OS1 did not have concerns about staff training for Parkinson's residents or supervision at the facility. OS1 noted that care for this population was nuanced, and an additional aspect was helping families to have realistic expectations of RCFE care. LPA interviewed OS2, a representative from an outside advocacy agency familiar with the facility. OS2 did not express concerns regarding supervision at the facility or how the facility cared for residents with Parkinson's Disease. (Continued on LIC9099 p.3)

Relevant records were reviewed regarding the allegation. In-service training records corroborated that the facility provided specific training to caregivers for Parkinson's residents with OS1 on 12/15/2025. Additional core training and onboarding training records for all caregiving staff included Demenia care, ADLs, community safety, elopement procedures/prevention, first aid, identifying risk, evacuation chairs, resident rights, pendant call system, skin management, stages of Alzheimer's Disease, incontinence care, transfer assistance, and lift devices.

LPA reviewed relevant records for the residents in question, including medical assessments, facility assessments, Needs and Services Plans, and care notes. The records corroborated staff statements regarding the situations that were presumed to be elopements. The records showed that each resident's initial assessment, upon admission, was aligned with the respective resident's assessment from their primary care physicians. The records additionally showed that the facility monitored each residents' condition and updated their plans of care according to their changing needs. Records showed that R2's responsible person was resistant to increasing the recommended services for R2's care plan, which increased R2's incidents of falling and attempts to exit the facility unassisted. Records showed that the facility updated R2's physician report regarding changes in behavior and requested a reassessment when R2 left the facility unsafely during an episode of agitation/disorientation. The facility paid for a personal 1-1 caregiver to provide increased supervision for R2. Staffing records showed that the facility scheduled 4-5 caregivers for each night shift in the Assisted Living section of the facility, in addition to a 24-hour nurse and Med Tech. The records showed that the staffing levels matched the acuity levels of the residents for that time of day.

During an unannounced facility visit, LPA directly observed 3 staff walking with Circle of Friends residents, the program that provides higher supervision for residents with mild cognitive impairments who do not yet meet the level of need for the memory care unit. One staff was facilitating the group and two other staff were on the periphery monitoring the group of residents. One male resident became agitated/disoriented and began arguing with the facilitator and was assisted back to their room by one of the caregivers. Facility census during this time showed that there 16 residents in the Circle of Friends program.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mark Ranno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.