Complaint·August 29, 2025

The investigation revealed the following: Allegation: Staff do not accord dignity to resident in care The allegation alleges that a resident tried to see the administrator and the door was closed and locked by staff and the administrator has not spoken to the resident about the incidents that have occurred at the facility. LPA received and reviewed staff In-Service Training Logs, regarding the Personal Rights of Residents signed and dated 03/18/2025. During the facility tour, LPA observed the Personal Rights of Residents posted in the hallway. LPA received and reviewed R1’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly signed and dated on 08/20/22, that states on page 2, they have the right “to be accorded dignity in their personal relationships with staff, residents, and other persons.” LPA received and reviewed documentation of S1 and R1 discussing the incidents that occurred that are signed and dated 08/19/2025. During interviews with Staff S1-S7, were asked if residents are treated with dignity, seven (7) out of seven (7) stated residents are treated with dignity. During interviews with Residents R1-R7 were asked if they are treated with dignity by staff, seven (7) out of seven (7) stated yes, they are treated with dignity by staff. Additionally, two (2) out of the seven (7) stated some of the staff can be rude. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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 . Allegation : Staff are not preventing resident in care from harassing other resident in care. The allegation alleges that a resident is being harassed by other residents who are making false allegations about them. During record review, LPA received and reviewed residents General Facility Information and House Rules provided to residents upon move-in, that states in number 3. “Disruptive or violent resident behavior: Disruptive or violent behavior whether it is verbal or physical abuse towards staff or other residents is unacceptable. The facility administrator will arrange a meeting with the resident and their responsible party to discuss any incident to ensure that such actions do not happen again. A second incident may result in a written warning that any continued disruptive or violent behavior can result in a notice of eviction.” Additionally, LPA received and reviewed incident reports dated 08/09/2025 and 08/15/2025, regarding police officers responding to the facility due to interactions between R1-R3. On 08/09/25, staff S8 heard R1 and R2 yelling at each other in R2's room. According to R1 and R2, they were arguing about money, towels, and a walker. S8 separated the residents and escorted R1 to their room. At 10:50PM S3 reported police had arrived. Police spoke with residents and staff. The police officers determined it was a civil matter and recommended staff to keep the residents separated. On 08/15/2025 at 8:45PM, R3 spoke with S4. R3 told S4 they wanted to call the police because they were afraid of R1. S4 told R3 that it's their right to call and make a report. During an interview with S4, stated R3 told them they were afraid R1 was going to hit them. Police officers came to the facility and spoke with residents involved in the incident. During interviews with Staff S1, stated Residents R1-R3 have been advised not to interact with one another, and that staff are present in common areas and during activities to ensure residents do not have a confrontation. During interviews with Staff S1-S7, were asked how they ensure a resident does not harass another resident, seven (7) out of seven (7) stated they provide supervision to residents while in common area, and if residents have an issue with another resident staff speak with them to resolve the issue or to ensure it does not escalate. During interviews with Residents R1-R7, were asked if they have been harassed by another resident, five (5) out of seven (7) stated no, they have not been harassed by a resident. Additionally, Residents R1-R7, were asked if staff prevent residents from harassing other residents, six (6) out of seven (7) stated yes, staff are there to prevent incidents and ensure there is no harassment. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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 . No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Administrator Assistant, Selena Cruz, and a copy of this report was provided.