Complaint·April 16, 2026

Allegation: Staff restricted residents from accessing their mobility devices. It was reported that staff #1 (S1) restricted residents from accessing their mobility devices. The reporting party alleged that night shift caregiver S1 took wheelchairs and walkers and placed them out of residence reach during the NOC shift. The reporting party did not provide the names of any specific residents allegedly affected. During the course of investigation, LPA conducted interviews with seven (7) out of fifteen (15) residents residing in the Memory Care Unit. All residents interviewed denied that staff took away their mobility devices and stated that they are always able to access their wheelchairs and walkers as needed and did not report concerns related to staff interfering with their mobility equipment. Residents also added that even during nighttime, their mobility devices are next to their beds for easy access. During the visit, LPA also observed that all residents had wheelchairs or walkers next to them and by their beds. LPA also interviewed staff members, who denied witnessing or hearing of any staff restricting residents’ mobility devices and stated that residents’ mobility equipment is kept available at all times. Furthermore, staff added that they would immediately notify supervisors if they observed any conduct that interfered with residents’ care or residents’ rights. Staff consistently stated that residents are provided with care and supervision in a professional manner. LPA interviewed the Executive Director (ED) and Memory Care Director (MCD), who informed that this issue was brought to their attention with anonymously written letters and they both conducted their internal investigation by conducting surprise night visits to the facility to ensure residents are receiving appropriate care and supervision. ED and MCD further stated that staff receive regular in-service training and are expected to maintain residents’ personal rights and dignity. Based on interviews and observations, because no specific resident was identified and no corroborating evidence was obtained, the allegations that staff restricted the resident from accessing their mobility devices is Unsubstantiated at this time. Continue on LIC9099-C Allegation: Staff fell asleep while on their shift. It was alleged that staff #1 (S1) working for NOC shift fell asleep while on shift. It was reported that on 4/6/25, Staff #3 (S3) found (S1) asleep in a recliner in room 117. During the investigation, LPA interviewed seven (7) residents. All residents interviewed denied observing staff asleep while on duty stated they have no concerns regarding night shift staff. Residents stated that staff is always available when needed and did not indicate any lack of supervision during nighttime hours. LPA interviewed staff members regarding the allegation, staff denied seeing S1 or any other staff sleeping while on duty. Staff also added that during the NOC shift staff get breaks and during their break time they rest. Staff stated they had not heard neither staff nor residents complain about S1 sleeping during the shift and reported that if such behavior observed, it would be immediately reported to supervisors. Staff also stated that all caregivers are expected to remain awake and attentive during their schedule shift to provide appropriate care. LPA intervied Executive Director and Memory Care Director, both of whom denied staff sleeping while on shift. Both reported that they conduct ongoing oversight of night staff, including surprise visits, to ensure staff are awake and providing sufficient care and supervision. Based on interviews, and no evidence to support the allegation that staff fell asleep while on their shift is Unsubstantiated at this time. Allegation: Staff handled residents forcefully while changing residents. It was reported that night shift caregiver Staff #2 (S2) pulled and shoved residents onto their beds while preparing to change their clothing and that residents were heard exclaiming “you're hurting me”. There were no specific names provided by reporting boarding. During the investigation, LPA interviewed seven (7) residents. Residents interviewed denied that staff handled them roughly during care or while assisting with dressing or changing. Residents did not report staff pulling, shoving, or hurting them during personal care assistance. LPA interviewed staff who denied witnessing or hearing S2, or any other staff member, handling residents in a forceful or inappropriate manner. Staff stated that residents are provided assistance with daily living in a respectful and professional manner. Continue on LIC9099-C Staff also added that they are mandatory reporters and would report immediately to management if observed neglect to residents. LPA interviewed the Executive Director and Memory Care Director, who denied receiving any confirmed reports that NOC shift forcefully handled residents during care. They stated they routinely supervise and monitor staff performance, including during night shift, to ensure residents are treated with dignity and respect. ED and MCD also added that staff receive regular training regarding resident care and personal rights. Based on interviews conducted, and because no specific residents were identified, the allegation that staff handled residents forcefully while changing is Unsubstantiated at this time. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.