The complaint alleged that staff contacted the responsible party after discovering residents in the facility's hallway who were shaking, unable to walk, and disoriented, instead of calling the Medical Emergency Service (MES). On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied the allegations. A1 stated that the facility has strict protocols in place. According to A1, there is no way the staff would fail to call EMS when necessary, and they likely informed the responsible party (RP) about the residents' conditions. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations. MDC affirmed that the facility is trained to call EMS in urgent situations, followed by contacting the nurse.

LPA Richard also interviewed four staff members, #1-4 (S1 to S4), all of whom denied the allegations and emphasized that resident care and well-being are their main priorities. After assessing the situation, the staff felt that resident R1 was stable and did not see the need to call EMS. Later that day, LPA Richard interviewed six residents #2-7 (R2 to R7). Five of the six residents denied the claim that the facility wouldn’t call EMS when needed, noting that the facility had called EMS for them on numerous occasions.

Report Continued on LIC9099C

At the same time, LPA reviewed R1's Physician List of Medications. R1 was prescribed Levothyroxine (Aricept) 10 MG Tablet; the side effects of this medication include dizziness and disorientation. On June 5, 2024, the facility called the RP, who indicated that R1 might be discharged that day. However, the Executive Director mentioned that R1 never returned to the facility after the hospitalization. The LPA was unable to interview R1, as R1 no longer resides at the facility. LPA Richard was unable to interview R1 because R1 moved out of the facility on 6/01/2024.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated.

Report Continued on LIC9099C

The complaint alleged that some residents had confronted others, and the staff failed to intervene. On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied these allegations. A1 stated that the facility staff would intervene and redirect the residents as needed. According to A1, this is a memory care facility. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations and affirmed that staff were trained to help redirect residents.

LPA Richard conducted interviews with four staff members (S1-S4), all of whom denied the allegations. They emphasized that the facility's main priorities are resident care and well-being. The facility employs many staff members who are present on the floor with the residents. In the event of any altercation, these staff members are readily available to intervene, although such incidents are rare.

Later that day, LPA Richard interviewed six residents (R2-R7). Five of the six residents denied the allegations and stated that the staff are always present to help redirect or assist the residents. During the visit, LPA Richard observed a significant number of staff on the floor engaging with the residents, participating in activities, watching TV, and conversing with one another. The LPA was unable to interview R1 because R1 moved out of the facility on 06/01/2024.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated.

The complaint alleged that the residents had numerous falls due to the facility leaving the residents unsupervised. On December 17, 2025, LPA Richard interviewed the Administrator (A1), who denied these allegations. A1 stated that the facility staff had never reported that R1 had falls. The facility had a protocol for unwitnessed and witnessed falls. According to A1, the staff will call the Nurse, not move the resident, and make sure the resident is not in pain. Additionally, LPA Richard interviewed the Memory Care Director (MDC) on the same day, who also denied the allegations and affirmed that staff were trained on how to approach witness and unwitnessed falls.

LPA Richard interviewed four staff members (S1-S4), all of whom denied the allegations. They emphasized that the facility's main priorities are resident care and well-being. They also stated they will call the nurse, ensure the resident is not in pain, and, if necessary, call EMS. Additionally, they mentioned that they checked residents' rooms every hour, with some being checked every half hour. Later that day, LPA Richard interviewed six residents (R2-R7). Five of these six residents denied the allegations and also stated that the facility checked their rooms every hour.

On December 17, 2025, LPA records reviewed the facility notes dated April 17 and May 8, 2024, showed that during a room check, the staff member found R1 sitting on the floor of the R1 bedroom. The staff asked if R1 was in pain and said they would call 911, but R1 refused and wanted to go to Urgent Care. The facility then called RP, who stated that RP would come and take R1 to urgent care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (S) did or did not occur; therefore, the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a copy of the report was given to the Executive Director, Marie Hill.