complaint·April 3, 2025

The investigation revealed the following: Allegation: Staff did not prevent resident from engaging in a physical altercation It is being alleged that facility did not come out of the facility while a resident in care was in a physical altercation out in the facility yard. On 03/12/25 between 10 am-11 am LPA conducted interviews with R1-R3 regarding the allegation above, 2 of 3 residents interviewed denied the allegation above, and reported being aware that the police were called to the facility but are unaware of the reason the police were called. 1 of 3 residents interviewed denied the allegation above, however 1 of 3 residents interviewed reported being involved in an altercation outside of the facility. On 03/12/25 LPA was unable to interview resident 4 (R4) due to communication barrier. On 03/12/25 and 03/19/25 between 11 am-11:40 am LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above, however 3 of 3 staff interviewed reported the police arrived at the facility due to an altercation between a resident and visitor that occurred outside of the facility. Per 3 of 3 staff interviewed there are procedures in place for when there is an altercation inside the facility which include informing the Administrator. On 3/18/25 LPA conducted review of R1’s physicians report dated 03/26/24 which indicates R1 does not require constant supervision, and R1 is able to leave the facility unattended. On 03/19/25 LPA conducted telephone interview with W1 regarding the allegation above, W1 denied the allegation above and reported there are no health and safety concerns regarding facility staff. On 4/3/25 LPA conducted a file review and observed that the facility sent an unusual incident report to the department on 3/5/25. On 4/3/25 LPA conducted a review of police report dated 3/1/25. Per police report, an incident occurred on 3/1/25 between R1 and another party which resulted in the other party to be arrested, not another action taken by police. In addition, the Police report states that the facility staff was not interviewed regarding the situation outside the facility. On 4/3/25 LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and reported that staff on shift will call A1 and inform A1 of the situation. A1 continued to state that staff were unaware of the incident that occurred on 3/1/25 as it occurred off facility property after midnight. Allegation: Staff did not prevent resident from having access to pepper spray. It is reported that a resident in care has possession of pepper spray. On 03/12/25 between 10 am-11 am LPA conducted interviews with R1-R3 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. 1 of 3 residents interviewed reported hearing a resident in care looking for pepper spray but did not observe any physical pepper spray at the facility. On 03/12/25 LPA was unable to interview resident 4 (R4) due to communication barrier. On 03/12/25 and 03/19/25 between 11 am-11:40 am LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. On 3/12/25 LPA conducted a facility tour, there were no health and safety concerns observed. On 03/18/25 LPA conducted a review of R1's personal property and valuables dated 02/24/25, LPA did not observe any documentation regarding pepper spray. On 03/19/25 LPA conducted telephone interview with W1 regarding the allegation above, W1 denied the allegation above and reported there are no health and safety concerns regarding facility staff. On 4/3/25 LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and report all belongings are documented upon admission to the facility. A1 continued to state that staff check bedrooms while cleaning and will remove anything that is found that is not allowed in the facility, per A1 pepper spray has not been found inside the facility. 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.