complaint·April 28, 2026

Allegation: Staff does not ensure adequate supervision is being provided to residents in care It was alleged that staff were not providing adequate care and supervision to residents by not regularly checking on residents’ whereabouts in the facility. According to the complaint, a visitor arrived at the facility and staff were unable to locate the resident the visitor was there to meet with. The resident was later located in their room taking a nap. The visitor claimed staff were unable to provide any details regarding the residents’ previous whereabouts and actions. LPA conducted interviews separately with three (3) staff members who were present on the day of the above incident and all of whom stated the allegations were inaccurate. All staff stated that on the day of the incident described above, R1 had just finished their lunch and had indicated to staff that they would prefer to rest in the afternoon, rather than participate in activities as they usually did. A family member of R1 had arrived to the facility and was unable to locate the resident in the activities room or any other common areas. R1’s bedroom door was closed and locked as well to prevent other residents from potentially disturbing R1 during their nap. All staff interviewed noted the family member had arrived during the PM shift change at the facility, thus, when R1’s family member asked several staff where they could find R1, oncoming staff responded with “I don’t know.” S1, who had been at the facility prior to shift change and remained at the facility during the incident, explained to the family member that R1 was in their room and other staff were unaware of R1’s whereabouts as they had just arrived for their shifts. S1 allowed the family member into S1’s room where they were still napping. Although the allegation may have happened, the preponderance of evidence has not been met. Therefore, the allegation is UNSUBSTANTIATED. Continued on LIC 9099-C Allegation: Staff did not ensure resident was fully clothed while in care It was further alleged that staff were not properly assisting R1 with dressing for the day, as indicated in R1’s care plan. LPA conducted interviews separately with three (3) staff members who were present on the day of the above incident and all of whom stated the allegations were inaccurate. Staff were in agreeance that R1 had requested to go to their room to rest following lunch. All staff reported that staff had provided R1 with a shower prior to having R1 lay down in their bed. S1 further reported that R1 had requested to lay down without pants on for comfort and R1’s clothing was placed next to their bed so R1 could be assisted with re-dressing once they had woken up. LPA reviewed facility shower logs and confirmed R1 was provided a shower from an AM shift (6:00 am – 3:00 pm) staff person on the same day as the allegation. Further, facility progress notes indicated that the resident did in fact have a visitor that afternoon, left the facility accompanied by family, and returned to the facility around dinner time where they then returned to their room to rest and watch television. Although the allegation may have happened, the preponderance of evidence has not been met. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report was provided to Executive Director, Stacey Baxter, via email.