complaint·October 15, 2025

The investigation revealed the following: Allegation: Staff engaged in an argument with a family member in front of the resident. It was alleged that the Executive Director engaged in a continuation of an argument with a family member in front of residents. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated in the common area of the facility, one of the residents’ family members entered wearing a body camera that recorded staff and residents, which is a violation of residents’ rights. On 08/11/2025 between the hours of 2:30pm – 3:50pm, and on 10/02/2025 between 10:00am – 2:12pm, LPA conducted interviews with 10 residents regarding the allegation. Ten (10) of ten (10) residents denied the allegation. All residents stated they did not hear or witness any arguments between staff and a family member on July 31, 2025. On 08/11/2025 between the hours of 2:15pm – 3:41pm, and on 10/02/2025 between 10:10am – 12:44pm, LPA conducted interviews with nine (9) staff members regarding the allegation. Three (3) of nine (9) staff denied the allegation, and six (6) of nine (9) staff were unaware of the incident. The six staff stated they did not recall or know of any incident occurring on July 31, 2025, while three were not on shift at the time of the incident. On 10/08/2025, LPA interviewed Witness 1 (W1) regarding the allegation. W1 stated that while in the great room with her mother, she heard a discussion involving differing opinions but did not hear any yelling or screaming. W1 stated she would have preferred that the discussion be held privately rather than in front of guests and residents. LPM Hammond interviewed Witness (W2) further stated that upon entering the facility with a body camera, Administrator (A1) observed W2, followed them throughout the building, and began yelling and screaming in front of residents and several family members, causing discomfort among both residents and their families. Report continues on LIC 9099-C On 10/15/2025 between the hours 09:00am - 09:15am conducted a record review and observed the following documents: On 08/02/2025, the department received a LIC 625: Unusual Incident/Injury Report (dated 07/31/2025) which stated R1's family member approached A1 with a body camera in the dining room on the third floor of memory care unit. A1 asked R1's family member to cease from filming as A1 did not consent to being recorded as well as its against policy and violates the resident's person rights. A1 made an attempt to de-escalate the situation by disengaging and contacting the Department of Social Service (DSS): Community Care Licensing (CCL). Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff locked residents out of their rooms. It was alleged that there was a continuous practice of the facility locking residents out of their rooms. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation and stated there were no circumstances in which residents were intentionally locked out of their rooms. On 08/11/2025 between the hours of 2:30 pm – 3:50 pm, and on 10/02/2025 between 10:00 am – 2:12 pm, LPA conducted interviews with 10 residents regarding the allegation. Ten (10) of ten (10) residents denied the allegation and stated they had never been locked out of their rooms by staff. On 08/11/2025 between the hours of 2:15 pm – 3:41 pm, and on 10/02/2025 between 10:10am– 12:44 pm, LPA conducted interviews with nine (9) staff regarding the allegation. Seven (7) of nine (9) staff denied the allegation, and two (2) did not confirm or deny it. The seven staff stated they were never instructed to lock residents out of their rooms, while the two were not present at the time of the alleged incident. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Report continues on LIC 9099-C Allegation: Due to lack of supervision, a resident defecated in the corner of the kitchen. It was alleged that due to a lack of supervision, a resident was searching for a bathroom and ultimately defecated in the corner of the kitchen. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that the resident had an accident in the kitchen and was unaware of how to manage it. Two of the staff were present and redirected the resident to her room, assisted with cleaning and changing, and then returned her to the common area. A1 explained that such incidents are common in memory care and are not typically reported to licensing, as they are part of the disease process. A1 also stated there are no cameras in memory care or assisted living common areas, only in certain resident rooms. On 08/11/2025 between the hours of 2:30pm – 3:50pm, and on 10/02/2025 between 10:00 am – 2:12pm, LPA conducted interviews with 10 residents regarding the allegation. Ten (10) of ten (10) residents denied the allegation and stated they had not witnessed or heard about a resident defecating in the kitchen area. On 08/11/2025 between the hours of 2:15pm – 3:41pm, and on 10/02/2025 between 10:10am – 12:44pm, LPA conducted interviews with nine (9) staff regarding the allegation. Nine (9) of nine (9) staff were unaware of the allegation and stated they did not witness or have knowledge of a resident defecating in the kitchen area. On 10/15/2025 between the hours of 9:20 am - 9:30 am, LPA conducted a record review and observed the following documents: LIC 602 Physician’s Report for Residential Care Facilities for the Elderly (RCFE), Resident Assessment, and Community Logs for Resident 2 (R2), which show no history of bowel incontinence or incidents of defecation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Report continues on LIC 9099-C An exit interview was conducted with Robert Jakini, Administrator, and a copy of this report was provided.