Allegation: "Facility is not sufficiently staffed to meet the needs of residents in care:"

The complaint alleges that there are not enough staff working in the facility to meet resident needs. Staff schedules were reviewed for the past month. Review of staff schedules revealed that there are five (5) care staff plus two (2) charge nurses on shift during the 06:00AM - 02:30PM shift. There are four (4) care staff plus two (2) charge nurses scheduled during the 02:00PM to 10:30PM shift. On the overnight shift, there are two (2) care staff and one (1) charge nurse scheduled. In addition, there are activity staff present daily, as well as management staff to assist during the day and evening hours. Interviews with staff revealed the current schedule is sufficient to meet the needs of residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegations: "Resident sustained multiple falls due to staff neglect" and "Facility staff did not adequately address resident's fall risk resulting in injuries:"

Interviews revealed that during the overnight shift that ended on 06/12/2026, R1 had awoken during the night. R1 attempted to get out of their bed and had slid to the floor four (4) times. R1 does have a bed alarm, so each time staff responded to R1's room to assist them. Interviews revealed that all residents are regularly observed every two (2) hours during the overnight shift. In the early morning hours of 06/12/2026, staff responded to R1's room every hour when R1 was getting out of bed. Additionally, R1 does have a landing mat next to their bed and R1's family provided R1 a lower bed to mitigate a potential fall risk. Interviews and documents reviewed revealed R1 has not fallen from a standing position while residing at the facility, but typically slides down to the floor when they attempt to get out of bed. Although R1 did hit their head on the wall at approximately 04:20AM on 06/12/2026, staff was present in R1's room at that time and was a result of a behavior, not a fall. Responding emergency personnel indicated "[patient] was assessed, no injuries found." R1 has not sustained any injuries observed when getting out of bed unassisted. Staff indicated that when R1 ambulates about the facility using their walker, staff do walk with R1 to ensure their safety. The information obtained during the investigation did not include evidence sufficient to corroborate the

Report Continued on LIC 9099-C (p.3)

Allegation: "Staff do not treat residents with dignity and respect:"

LPA and Investigator Trainee interviewed staff and family members related to this allegation. No staff interviewed reported ever observing any other staff not treating residents with respect. Additionally, no staff or management interviewed reported hearing any reports related to treating residents disrespectfully. Family members interviewed indicated they have no concerns with the staff or their interactions with the residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.

allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: "Staff did not notify authorized representative of incident:"

On the morning of 06/12/2026, when R1 slid off their bed, it was alleged that staff did not notify R1's responsible person timely. Interviews revealed that R1 slid off their bed at approximately 04:20AM and staff did call 9-1-1 as R1 had been observed hitting their head on the wall as a behavioral expression once R1 was on the floor. The charge nurse called emergency services and tended to the resident's needs. Emergency services responded to the facility at 04:30AM and charge nurse began talking to emergency personnel to inform them of R1's status. At that time, one of the emergency personnel called R1's authorized representative and informed them of the incident. According to R1's family member, within ten (10) minutes, R1's family member talked to the facility charge nurse over the phone related to the incident. R1's family member felt the time frame was sufficient and denied the allegation. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: "Staff did not address a resident's change in medical condition in a timely manner:"

The complaint alleges that at the time of the incident, R1 had a change in condition, which was not addressed. Records reviewed revealed R1 had been tested for a urinary tract infection (UTI) on 06/11/2026, which resulted in a positive diagnosis. Facility staff had notified R1's physician and requested orders for antibiotics. Additionally, Director of Health Services also sent a request to R1's primary care physician to review R1's prescribed medication for potential changes. This request was sent on 06/12/2026 at 08:47AM, just after R1 had slipped out of their bed. Additionally, interviews revealed facility staff have been in regular communication with R1 and their responsible party related to changes with R1 and their care needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099-C (p. 4)