Complaint·June 3, 2026

Continued from LIC9099 W1 was near R2 when R1 came up and grouped R2. W1 yelled at R1 and a Medical Technician, (Med-Tech) came out to assist. W1 said W1 did not look for staff, nor yell for staff to assist. W1 only yelled at R1 which prompted the Med-Tech to come assist. S1 reported the behavior to the department in an Unusual Incident Report (LIC624) and reported it to both responsible parties. S1 informed LPA that R1 is new to the community. R1 has a lack of impulse control and dementia. LPA confirmed this by reviewing R1’s Physician’s report. S1 informed LPA that R1 will touch other residents or staff and ask if that person wants to be R1’s friend. R1’s does this in a friendly manner that can be interpreted as sexual due to R1’s impulse control and hand placement. S1 informed LPA staff will redirect R1 and remind R1 not to touch. S1 has said this behavior has never escalated beyond the initial touch and over the last few weeks has all but stopped. LPA reviewed staff roster and schedule. LPA toured the facility and counted six (6) staff present. R1 does not require one-on-one supervision, and staff were within eyesight while LPA toured the facility. R1 was seen dancing and socializing with many other residents. R3, R1’s roommate informed LPA that R1 has never exhibited those behaviors in their room, nor has R1 brought someone into the joint room. Based on interviews conducted and LPAs observations the above allegation is UNSUBSTANTIATED. Allegation: Staff are not meeting residents needs Investigation Findings: It was reported to the department that a visitor had to assist a resident in finding a staff member to assist, and that the facility seems to rely on goodwill visitors to assist residents. W1 stated W1 will go up to residents and that look like they need assistance and guide them to find a staff member. W1 stated W1 does not seek a staff member first. W1 admitted to taking it upon W1’s self to assist and thus feels there is a lack of staff. LPA reviewed the facility staff roster and did a head count confirming there was plenty of staff present to assist residents. LPA interviewed R1, R3 and R4 separately. Each stated they feel their needs are being met and feel there are sufficient staff to assist. Based on interviews conducted and LPA observations the above allegation is UNSUBSTANTIATED. Allegations: Staff did not prevent a resident from entering another residents room Investigation Findings: It was reported to the department that one resident was seen entering a room of two other residents, both of whom shoved the resident out. W1 reporting seeing R5 walk into a room that R5 does not occupy and being shoved out by the two residents who do occupy that room. W1 stated W1 had to intervene, take R5’s arm and lead R5 away. Again, W1 did not seek staff assistance, nor look for staff before helping. LPA spoke with S1 and reviewed R5’s physician’s report. R5 is visually impaired and uses handrails along to walls to navigate. R5 was not intentionally trying to gain access to another resident’s room. R5 simply got lost and missed R5’s room due to R5’s lack of vision. LPA toured the facility and noted residents do keep their doors open. As such, any resident can walk into another’s room though LPA did not observe this happening. S1 informed LPA that staff are working with R5 to assist R5 in better memorizing the layout of the facility and finding R5’s room, however with R5 having dementia, R5 is having some difficulty. To mitigate this, staff are reminded to look out for R5 and offer a redirect should R5 seem lost. Based on interviews conducted and LPA observations the above allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.