Complaint Investigation Report

The investigation revealed the following:

Allegation: Licensee is retaining a resident whose needs cannot be met

The allegation alleges there is a resident who was improperly accepted in the facility’s Memory Care Unit, whose needs cannot be met due to an additional diagnosis of mental illness.

During record review, LPA received and reviewed Resident R1’s Medical Assessment for Residential Care Facilities for the Elderly (dated 03/31/2025 & 03/18/2026), that indicates R1 was admitted to the facility with the initial diagnosis of Mild Cognitive Impairment (MCI). As of 03/18/2025 R1 has a dual diagnosis of MCI and a mental disorder. LPA observed on the Medical Assessments no aggressive behavior was indicated and no behavioral expressions indicated. LPA received and reviewed an Evaluation, through Tolwin Psychiatric Medical Group, conducted on 08/05/2025 that states staff reported R1 has not exhibited behavioral disturbances requiring intervention. Additionally, LPA received and reviewed a Follow-Up Evaluation, through Tolwin Psychiatric Medical Group, conducted on 04/07/2026 that states “no behavioral problems or safety concerns were reported. R1 remains directable though unpredictable at times.” Both reports indicate R1 was cooperative, guarded, and calm. LPA received and reviewed Resident Assessment/Service Plan, dated 04/05/2025, that indicates R1 may exhibit physically or verbally aggressive behavior and agitated or anxious behavior. Additionally, R1 may exhibit behaviors requiring staff intervention/redirection once per shift.

During interviews with Staff S1-S6, were asked if they feel R1 requires a higher level of care, six (6) out of six (6) stated yes, after the past 6 weeks, they believe R1 requires a higher level of care. Additionally, during interviews with S1 and S2 stated they have been working with R1’s psychiatrist and case manager to find a more appropriate placement for R1.

During interviews with Residents R2-R12, were asked if they have any concerns regarding them or a resident requiring a higher level of care, eleven (11) out of eleven (11) stated no, they have no concerns regarding a resident requiring a higher level of care.

Allegations: Staff do not prevent resident from harming other residents

The allegation alleges an ongoing risk from a resident who is attacking staff and other residents.

During record review, LPA received and reviewed staff Orientation/In-Service Sign-In Sheets for Training staff received in June 2025 and November 2025. The topic for the training in June 2025 was Behavior + Interventions in Dementia and the topic for the November 2025 training was Behavior Management & Dementia.