complaint·February 6, 2026

The Investigation Revealed the Following: Allegation: Staff lock resident(s) in their room while care. It is alleged that R1 and R2 are locked in their room at night. LPA interviewed 3 staff and each denied the allegation, they stated that the door does not have a lock but a hook that is able to be opened from both the inside and outside of the bedroom door that both R1 and R1 reside in. LPA inspected door and there was a hook on both sides of the door, staff demonstrated door to LPA and how it is easily opened from both sides at any time. LPA also had R1 demonstrate how they would be able to open the door in the case the hook is latched and R1 was able to successfully able to open the door with ease. Staff also stated that the door is never locked, the only time the latch is used Is when the residents need privacy to change clothing or their diapers as the door sometimes opens on its own without latch, staff stated they do not use latch to close the door at night. LPA interviewed family/Power of Attorney (POA) for R1, R3 & R4, each denied the allegation, stated they have never observed residents being locked in their rooms & have never had this concern. Allegation: Licensee does not ensure that resident(s) have access to an emergency call system while in care. It is alleged that there is no way for residents to call staff in event of an emergency during night hours. LPA toured facility and observed residents call buttons, R1 was wearing their call button and this was tested during visit and was observed to be operable. LPA interviewed 3 staff and each denied the allegation and stated that each residents room has an Audio Only Nanny speaker that will notify staff if someone is calling for help and each resident has a call button that they either wear as a necklace or have near their bedside for easy access. LPAs interviews with family/POA for R3 and R4 and denied the allegation and stated that they have seen the call buttons and speaker in the residents rooms but have not had to use them. Allegation: Staff do not ensure that resident(s) are provided activities while in care. It is alleged that activities are not provided for the residents to engage in. LPA toured facility and observed supplies such as card games, puzzles, bingo, magazines and art supplies and observed Residents painting, and R1 doing exercises with physical therapist. Interview with R1 revealed that they have participated in some of the activities at the facility and enjoy bingo, listening to music and doing artwork. LPA interviewed 3 staff, and each denied the allegation and stated that activities are provided for the residents, however, it varies as some residents sometimes prefer not to participate, other activities will be offered but due to their cognitive disabilities they sometimes decline the activities. LPA interviews with family/POA for R3 and R4 and denied the allegation and stated that they have visited the facility and can confirm that activities are provided to the residents, interview with POA for R1 stated that although they cannot visit often due to distance they are provided with updates and photos of what R1 did for the day and the activities they participated in. (Continued on LIC9099-C) Allegation: Staff emotionally abused resident(s) in care. It is alleged that staff play loud music to avoid having to respond to residents. LPA interviewed 3 staff and each denied the allegation, both S1 an S2 stated that R1 enjoys listening to music and has asked to have music played louder so they can hear better but this was per the request of the resident and not to emotionally abuse residents. LPA interviewed R1 and they confirmed they enjoy listening to music and it has never been played too loud. LPA interviewed the family/POA for R1, R3 and R4 and each denied the allegation and stated they have never observed music being played too loud at the facility before, interview with POA for R1 stated that R1’s family member mentioned that one day the music was played loudly when they arrived but when the staff was asked to turn it down they did so immediately. Allegation: Food services are inadequate. It is alleged that R1 is being provided with foods that they are unable to eat due to not having ability to chew solid foods properly. LPA interviewed 3 staff and each denied the allegation, interview with S2 revealed that all residents are on a soft food diet and facility ensures that this is being met by thinly slicing all meals and avoiding any hard foods. LPA interviewed R1 and they denied the allegation and stated the food is not hard to chew and they enjoy the food at the facility. LPA interviewed the family/POA for R1, R3 and R4 and each denied the allegation and stated they have not had any concerns of the food at the facility and staff accommodate their family with foods they prefer. LPA checked food supply and there was sufficient amount of food at the facility to meet the needs of the residents. Per R1's Physician Report there is no special diet. Allegation: Staff do not accord privacy to resident(s) in care. It is alleged that staff put a commode next to R1 and R2’s beds so if they need to urinate at night, they must do it in front of each other with no privacy. LPA toured room and observed commode in R1’s closet, along with sufficient supply of incontinence care products. LPA interviewed R1 and resident stated that they were using the commode because they were having difficulty making it to the restroom on time, however, they now prefer to use their incontinence diaper when they need to use the restroom in the late-night hours. LPA interviewed 3 staff and each denied the allegation and stated that the commode’s are only used if needed in the late-night hours, residents are assisted and encouraged to use the restroom, however, there may be times when the resident cant make it to the restroom and that is when the commode is used. S1 and S2 stated that R1’s POA was the one who requested for the commode to be in R1’s room in the case of emergency and interview with R1’s POA they confirmed this to be true. Interviews with family/POA for R3 and R4 denied the allegation and stated they have not seen any of the residents use a commode during visits and have seen staff assist residents to the restroom. (Continued on LIC9099-C) Allegation: Staff do not accord dignity to resident(s) in care. It is alleged that staff at the facility are unprofessional and intimidating towards residents. LPA interviewed 3 staff and each denied the allegation and stated they have never acted unprofessional or intimidating towards residents and have never seen another staff be this way towards residents. LPA interviewed R1 and R1 denied the allegation and stated that all staff have been friendly and respectful. LPAs interviews with family/POA for R1, R3 and R4 and denied the allegation and stated that all staff have been great with the residents and have never witnessed staff act unprofessional or intimidating towards residents. Interview with family of R4 stated that although some may appear to be intimidating they have never witnessed staff to be anything other than kind, professional, caring and helpful towards the residents in care. Based on statements/interviews conducted with staff/residents/POA’s/Family of Residents, review of R1's file and LPA’s observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.