Incident #1: On 02/23/2026, it was alleged that Staff #1 (S1) called Resident #1 (R1) “stupid” and repeatedly questioned why they were confused. Once the facility became aware of the allegation, staff followed protocol and initiated an internal investigation. The appropriate agencies, including Licensing and Ombudsman, were notified. R1 was interviewed, and S1 was immediately suspended pending the outcome of the investigation. S1 was interviewed and provided in-service training regarding professional interactions with residents with memory impairment.

Incident #2 On 02/28/2026 it was alleged that Resident #2 (R2) disclosed to their Power of attorney (POA) that “A man took me downstairs and molested me”. Once the facility became aware of the allegation staff followed protocol and initiated an internal investigation. The appropriate agencies, including Licensing and Ombudsman, were notified. R2 was evaluated by the facility LVN, POA refused transport to the emergency room for further evaluation, however agreed to a virtual telemedicine physician visit. Primary care physician was contacted and provided a copy of the report, and the police were notified #26-26-884.

During today's visit, LPA and staff toured the physical plant area inside and out to ensure there were no immediate health and safety concerns. Report Continued on LIC 809C...

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Incident #1: Documentation revealed that Resident #1’s (R1) Physician’s Report dated 11/25/2024 lists dementia as the primary diagnosis. The assessment and service plan dated 11/18/2025 indicate that R1 receives assistance with medication management, housekeeping, laundry, and hands-on assistance with bathing, dressing, grooming, continence care, toileting, transferring, and fall-prevention interventions. The MDS-COGS assessment dated 08/26/2025 scored 6, indicating low-to-moderate impairment. The Montreal Cognitive Assessment (MoCA) dated 09/25/2025 scored 11/30, indicating significant cognitive impairment. S1 has no history of disciplinary action. On 03/02/2026, S1 conducted an in-service training regarding expectations for professional communication with residents, including appropriate approaches when working with individuals living with dementia. The facility’s internal investigation was completed, and S1 returned to work on 03/03/2026.

Interview with the Director of Resident Care Services (DRCS) revealed that A third-party companion reported that R2 stated a staff member had called them “stupid” and repeatedly questioned why they were confused. The facility immediately notified the Executive Director, suspended the staff member, and initiated an investigation. During interviews, the resident stated they did not recall being called “stupid,” though they remembered disliking the staff member’s tone and were unable to identify or describe the individual. A full body assessment on R2 confirmed the resident was safe with no concerns noted. Following interviews with all involved parties, S1 denied the allegation, has no history of misconduct and was reinstated. The resident requested that the S1 not be assigned to them moving forward.

Interview with R1 revealed that they did not recall the incident or being called “stupid.” R1 stated they previously disliked the tone of a staff member but could not recall who the staff member was or what they looked like. Resident interviews indicated that residents feel safe within the community and reported that staff treat and speak to them with respect. Residents reported no concerns regarding the quality of care or staff conduct.

Staff interviews indicated that they have never witnessed nor engaged in disrespectful behavior toward residents, including calling a resident “stupid.” Report Continued on LIC 809C PAGE 3...

Incident #2: Documentation shows that R2’s Physician’s Report dated 10/30/2025 lists dementia as the primary diagnosis. The assessment and service plan dated 10/29/2025 indicate that R2 requires assistance with medication management, housekeeping, and hands-on assistance with bathing, dressing, and grooming. R2 also requires reminders and cues for continence and toileting, reminders to use assistive devices, and occasional redirection and guidance. A Montreal Cognitive Assessment (MoCA) dated 10/29/2025 scored 17/30, indicating moderate cognitive impairment. Telemedicine documentation dated 02/28/2026 shows that R2 was seen for an urgent care visit and presented with dementia accompanied by delusions. The physical exam noted R2 to be healthy, well-nourished, and well-developed, with no acute distress. The assessment included delusions and dementia with psychotic disturbance, with dementia severity and type listed as unspecified. An in-service training was conducted on 03/02/2026 regarding appropriate responses to resident allegations of abuse, neglect, or inappropriate conduct.

Interview with the DRCS revealed that R2 reported to their POA that a man had entered thier room at night and attempted to “make out” with them, later describing the event as an attempted sexual encounter but stating they did not believe they were touched, harmed, or assaulted. R2 was unable to describe the individual and provided inconsistent details, at one point saying multiple men were involved and later stating it was one person. A nursing assessment found no injuries, no pain, and no signs of trauma, and the Sheriff’s Department responded and obtained statements from the resident and staff. The resident’s primary care provider, who is familiar with R2 history of dementia with delusions, advised that an ER visit was not necessary and adjusted their medication. The facility completed an in-service training with staff on responding to allegations of abuse, and the POA expressed that they believe the report was related to the resident’s dementia but wanted it documented. During the visit R2 refused to be interviewed. Resident interviews indicated that residents feel safe within the community and reported that staff treat and speak to them with respect. Residents reported no concerns regarding the quality of care or staff conduct. Staff interviews indicated that no residents have ever disclosed abuse to them. Staff stated that if a disclosure were to occur, they are required to report it immediately per facility protocol.

No deficiencies were cited at this time. A supplementary report or visit will be conducted if warranted Exit interview conducted. Report was reviewed and a copy was provided.