complaint·June 23, 2025

Investigation revealed the following: #1-Allegation: Resident was physically abused while in care On 4/15/2025, at 11:15AM, LPA interviewed Staff 1- Staff 5 (S1-S5), and 5 out of 5 stated they did not witness R1 being physically assaulted by R2 and were unable to establish a timeline for the alleged incident. However, all (5) five staff members reported noticing unexplained bruising on R1's face immediately after going into their room. Staff also stated they observed additional abdominal bruising within hours. LPA Allen interviewed R1 with the assistance of S2 as a translator. When asked if R2 physically abused them while in care, R1 stated that R2 had punched them in the face, mouth, and stomach. LPA attempted to interview R2, but they were not present at the facility during the investigation. LPA Allen obtained a police report reflecting R1 was physically assaulted while in care. LPA Allen also interviewed W1, who stated that upon arriving at the facility, R1 and R2 were questioned and R2 admitted to attacking R1 and was immediately taken into custody. Paramedics were called, and R1 was transported to the Emergency Room (ER) for further observation and determined that R1 was physically assaulted by R2. #4- Allegation: Staff had inadequate record keeping for a resident - On 4/15/2025, at 11:15AM, LPA interviewed Staff 1- Staff 5 (S1-S5), and 5 out of 5 stated upon the paramedic’s arrival, no records or medical information were available for residents R1 or R2. The interviews conducted with Memory Care Director Deeyanna Banda and Administrator Brittany Kavanaugh both stated that no records had been prepared for either resident prior to the altercation. When LPA arrived at the facility and inquired about the absence of records, Deeyanna and Brittany explained that R1 and R2 were newly admitted as displaced individuals who arrived without any identification, medical history or documentation. As a result, their files were not created until after the incident occurred. B ased on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report was discussed and provided to Brittany Kavanaugh- Administrator at the conclusion of the visit with appeal rights. Per Administrators approval Joseph Wieder was authorized to sign the report. Investigation revealed the following: #2 Allegation- Resident was sexually abused while in care On 4/15/2025 LPA conducted interviews with staff members S1- S5 and 5 out of 5 staff members stated they did not witness or hear R1 being sexually abused by R2. Additionally, none of the staff members were able to corroborate the allegation or establish a timeline for the alleged assault that could have happened. LPA interviewed R1, who stated that they had not been sexually assaulted by R2 only physically punched in their face and stomach. LPA attempted to interview R2; however, R2 was not present at the facility during the investigation. LPA Allen also obtained and reviewed a copy of R1’s medical summary, which did not indicate any evidence of sexual assault. LPA Allen also interviewed W1, who stated that upon arriving to the facility, both R1 and R2 were questioned, and R1 denied ever being sexually assaulted by R2 additionally, R2 did not confirm or deny the sexual allegation took place. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Brittany Kavanaugh Administrator at the conclusion of the visit. #3 Allegation- Staff did not properly report an incident involving a resident On 4/15/2025, LPA conducted interviews with staff members S1- S5. 5 out of 5 staff members stated they did not witness or hear of an occurrence that R1 was being sexually abused by R2. The staff members stated that when R1 was observed wit visible abrasions to their face and body it was immediately reported and documented to management the same day. The police was also contacted the same day of the incident and upon arrival they interviewed R1, R2 and staff members. Although staff and residents were interviewed a timeline could not be established as to determine when the incident occurred and the incident was self reported by facility management, the police was called , and Department of Social Services was contacted and facility staff provided the LIC624 and SOC341. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Joseph Wieder at the conclusion of the visit with appeal rights. Per Brittany Kavanaugh.