Complaint Investigation Report

9099C-1. Resident (R1) moved to the community in September 2023 with diagnosis of Dementia. (R1). The physician's report (LIC602) (completed on 7/22/2024) states that (R1's) primary diagnosis of Dementia is "longstanding, gradually worsening over time" and (R1) is needing some assistance with most ADL's. (R1) "has been on Memantine for some time" and "now with worsening behaviors has been throwing things at memory care, yelling, no clear triggers" but staff at the memory care state (R1) has "worse behaviors after (the family member) visits". The LIC602 notes (R1) has multiple secondary diagnoses, including Behavioral Change, Cataracts Bilateral, decreased vision in both eyes, and falls. The LIC602 also notes (R1) has aggressive and wandering behavior.

Allegation: Staff does not provide adequate supervision resulting in resident falling and sustaining bruising. The allegation states that on 10/6/2025, resident (R1) was observed to have dark purple bruising on their neck and face which was sustained when (R1) fell while trying to rise from their seat at a table in the facility's dining room. (R1) was observed on 10/07/2025 and noted to have a swollen area above their left eye (on their eyebrow area ) that was purplish in color with bruising running down the left side of their face to the middle of her neck and photos were provided to the Department. The facility states that (R1) rose from their seat, tripped, fell and hit their face on the floor, but there was no explanation provided for the bruising to their neck.

(R1’s) family member stated in October 2025 that they are at the facility regularly and for the past month, has been trying to tell the staff that (R1) is a fall risk. This family member stated they believe (R1) sustained bruises to the face and neck because staff, (S1), who works on the "pm" shift, did not provide supervision as she leaves the dining area and cannot be found.

The administrator stated on 10/15/25 that (R1) "cries, yells and tries to hit staff" and confirmed an incident report was submitted was submitted to the Department on 10/2/2025 for a "witnessed fall" on 10/1/2025.

The Administrator added that she was recently made aware that (R1’s) family member has been regularly visiting (R1) late, up until around midnight, and the visit will usually take place in the halls or TV area.

The administrator stated these late visits have been "disrupting (R1’s) sleep pattern" and (R1) is "very tired" when woken up at 7:00 am for breakfast, stating that (R1) is only getting a maximum of (7) hours of sleep each day. The administrator explained that (R1) "wanders, cries and hits their head on the wall” as they miss their family member after the visit ends.