complaint·December 11, 2025

Allegation: Staff locked residents in their rooms. It was alleged that residents in a Memory Care Unit are kept locked in their rooms. To investigate this allegation, LPAs conducted an interview with the Administrator and Memory Care Director. Both parties denied ever witnessing or hearing residents being locked in their rooms. LPAs were informed that the doors can only be locked from inside by the residents. However, all staff members have a master key and can easily gain access. Interview with three (3) staff members revealed that a Memory Care Unit currently has two (2) wandering residents. LPAs were also informed that when residents are out in common areas all residents’ doors are kept closed but not locked to prevent wandering residents from entering. Interview with staff also revealed that all Memory Care Unit residents’ doors are always unlocked when the resident is in the room, and the staff checks on them every hour. LPA visited four (4) random rooms and observed that the doors have no auto lock and can easily be opened. However, if the door is locked from the outside only a staff member with master key can gain access. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Allegation: Staff did not change residents in care To investigate this allegation, LPAs conducted an interview with the Administrator and Memory Care Director. Both parties denied the above allegation and informed LPAs that all incontinent residents are scheduled to be changed every two (2) hours or as needed. Three (3) staff members interviewed corroborated with the information provided by the Administrator and Memory Care Director. Additionally, LPAs conducted an interview with one (1) witness, who also denied the above allegation and stated that they visit their loved one twice a week and always witnessed staff changing residents frequently. Lastly, nine (9) out ten (10) residents interviewed also expressed no concern regarding the above allegations. During LPA's tour of the facility, there were no noticeable odors of incontinence and all residents were appropriately dressed and well taken care of. Based on information obtained through interviews and LPAs observation this allegation is deemed Unsubstantiated at this time. No deficiency issued during today's visit. Exit interview conducted, appeal rights explained and copy of this report delivered.