Complaint·September 11, 2025

On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. Allegation: Staff did not prevent residents from smoking in their bedroom. It is being alleged that facility staff are allowing residents in care to smoke cigarettes in their bedroom and bedroom balcony. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 10 of the 11 residents interviewed denied the allegation above. 1 of the 11 residents interviewed confirmed the allegation above and reported calling staff members for help, however, by the time the staff arrives to the bedroom the resident smoking is no longer in the bedroom and there is no evidence that smoking occurred. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 6 of the 7 staff interviewed denied the allegation above, however report that residents that have been caught smoking in a bedroom are redirected to the smoking patio and are reminded of the facility rules. 1 of the 7 staff interviewed did not have any information regarding the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. On 09/11/25 LPA conducted review of facility notes dated 8/11/25 and 09/03/25, facility notes indicated that resident in care has made reports of peer smoking in the bedroom, however staff have not observed any proof that cigarette smoking has occurred. Allegation: Staff did not prevent a resident from threatening another resident. It is being alleged that facility staff are not calling the police when a resident is threatened by a peer. On 09/10/25 and 09/11/25 LPA conducted Interviews with R1-R11 regarding the allegation above. 9 of the 11 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of the 11 residents interviewed denied the allegation above, however stated that a peer has threatened resident but it was not reported to staff. 1 of the 11 residents interviewed confirmed the allegation above and stated that staff was able to assist but the police was not called. On 09/10/25 and 09/11/25 LPA conducted interviews with S1-S7 regarding the allegation above, 7 of the 7 staff interviewed denied the allegation above. On 09/11/25 LPA conducted interview with W1 regarding the allegation above, per W1 there are no safety concerns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.