complaint·August 27, 2025

Allegation: Due to lack of supervision, residents are going into resident rooms The allegation alleges that staff do not prevent residents from going into another resident’s room. During the facility inspection, LPA observed the Resident Rights and House Rules posted in the hallway in the entrance of the facility. Additionally, LPA observed there are cameras in common areas and hallways in the facility. LPA received and reviewed the Admission Agreement (dated 04/14/2021 that states on Page 8, number 12, titled Facility Visiting Policy states “b) Rooms are available for confidential visits and d) Visiting between facility residents should be done in common areas in the facility. Such visiting in shared resident rooms is permissible providing the resident's roommate does not object to such.” Additionally, LPA received and reviewed the Attachment 2 - House Rules - page 17 number 13. that states Visiting is encouraged to take place in common areas. LPA reviewed resident’s Narrative Charting that states R1 was observed, by staff entering the wrong room and was redirected to the correct room. LPA was informed name plaques were added to doors for residents to know which room is theirs. During interviews with Staff S1-S8, were asked how they ensure unwanted residents or visitors do not enter a residents room uninvited, eight (8) out of eight (8) stated they supervise residents and if they see a resident enter another residents room they go ensure it is okay for them to be in there by both residents who’s room it is. Additionally, Staff S1-S8 were asked if there have been any incidents or complaints of a resident or visitor entering a resident’s room uninvited, four (4) out of eight (8) no, there have been no complaints or incidents of a person entering a resident’s room uninvited. Two (2) out of eight (8) stated a resident complained their roommate brought visitors into their room. And two (2) out of eight (8) stated a resident wandered into a room that was not theirs. During interviews with Residents R1-R11, were asked if they feel there is enough staff to provide supervision to the residents, ten (10) out of eleven (11) stated they feel there is enough staff to provide supervision to the residents. Additionally, Residents R1-R11, were asked if they had another resident or visitor enter their room without their permission, two (2) out of eight (8) stated they have had a visitor or resident enter their room uninvited, one stated a resident wandered in and the other stated their roommate brought visitors into their room without asking. Allegation: Due to lack of supervision, residents are having inappropriate interactions. The allegation alleges that a resident is having inappropriate interactions with a visitor. During the facility inspection, LPA observed Residents Personal Rights posted in the lobby of the facility. During record review, LPA reviewed R1's Personal Rights in Privately Operated Residential Care Facilities for the Elderly (LIC613-C), signed and dated by R1 on 04/13/2025. Both listings of Residents Personal Rights, states that residents have the right “(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.” It additionally states residents have the right “(8) to make choices concerning their daily life in the facility.” During interviews with Staff S1-S8, were asked if any residents have reported unwanted inappropriate interactions with another resident or a visitor, eight (8) out of eight (8) stated no residents have reported unwanted inappropriate interactions. Additionally, staff S1-S8, were asked if any residents have reported another resident or visitor forcing themselves on them, eight (8) out of eight (8) stated there have been no report of a resident or visitor forcing themselves on a resident. Staff S1-S8 were asked what the procedure is if it becomes known that residents are having a sexual interaction, eight (8) out of eight (8) stated the residents will be spoken to individually to ensure the encounters are consensual. During interviews with Residents R1-R11, were asked if they have experienced unwanted inappropriate interaction with a resident or visitor, eleven (11) out of eleven (11) stated no they have not experienced unwanted inappropriate interactions with another resident or a visitor. Additionally, Residents R1-R11 were asked if they feel safe in the facility, eleven (11) out of eleven (11) stated yes, they feel safe living in the facility. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . LPA did not observe or cite any deficiencies. An exit interview was conducted with Wellness Director, Kristen Sison, and a copy of this report was provided.