Complaint Investigation Report

revealed resident had history/or treated for UTI infection, with other health issues including but not limited to muscle weakness with atrophy hemiplegia and hemiparesis affecting right dominant side. R1 skin assessment and nurse notes date from 6/12/25 – 09/12/25 reveal small skin tear elbow area, rash, pain in foot noted including notes that interested parties contacted. Per incident report dated 10/21/25 R1 transferred to hospital to prevent complications from cut on toe and expired while still under hospital care on 10/20/25. Interview with interested party confirmed R1 was transferred from facility around September 2025 and did not return to facility but unable to provide additional information.

Interviews with six (6) of (6) six residents revealed they haven’t sustained any unexplained injuries or developed any infections at the facility. All residents interviewed stated staff are really nice, attentive, receive adequate care and have no concerns regarding the allegations. Interviews with five (5) of six (6) staff indicated they have been recently hired under new management and/or have no knowledge of R1 having aforementioned injuries and infections. One (1) of six (6) staff revealed R1 had been admitted to hospital due to declining health but doesn’t recall any relevant information. All staff interviewed stated they consistently provide residents with timely and attentive care and supervision, and they have not observed any mistreatment, carelessness, or neglect by other staff who are providing care to residents.

Based on the information obtained during the course of this investigation, there is insufficient evidence to support the above allegations. Although the allegations may have happened or is valid, there is not preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

Exit interview conducted/Copy of report given.