complaint·September 24, 2025

Witness (W1) reported it to Staff 1 (S1). R1 resides in memory care which has a secure perimeter with delayed egress exits. S1 attempted to assist R1 but R1 was not responding to S1. S1 called for Staff 2 (S2) to assist. W1 reported to law enforcement that S1 and R1 began punching each other. W1 reported to LPA that they did not actually see S1 hit R1 but assumed they were being hit because R1 was yelling. W1 reported to law enforcement that R1 was yelling, “Kill her. Kill her.” W1 reported to LPA they didn’t remember what R1 said. S1 reported that R1 had defecated in the hallway, and they wanted to get them out of their clothing and shoes because they were soiled. S1 stated that R1 became combative and tried to hit them. S1 stated that R1 started to lose their balance and started to fall so S1 held them up so they would not fall. S1 stated that they called S2 who came and took off R1’s shoes and asked R1 to walk to their room and R1 started to walk to their room. S1 and S2 both reported that once in the room they showered R1, put clean clothes on R1 and put R1 to bed. S1 denied hitting R1 and reported they have never abused any residents. S2 reported they did not witness S1 hit or abuse R1 in any way. No other staff members or witnesses were present during the incident. Law enforcement took a report on September 23, 2021, but did not take any action. LPA attempted to interview R1 but R1 did not recall the incident. Based on the evidence gathered, the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, resident sustained injuries while in care, revealed the following. It was alleged that Resident 1 (R1) sustained bruises on their forearms which were caused by facility staff. R1 was interviewed but did not recall how their arms were bruised. 5 out of 5 staff interviewed were unaware of R1 bruising until they were told about it. 5 out of 5 staff interviewed denied causing any injuries to R1 or any residents. The General Manager stated that R1’s responsible party informed them of the bruise and asked staff about it but no one could explain how it occurred. None of the staff interviewed could explain how R1 sustained their bruises. R1 resides in memory care which has a secure perimeter. R1 is on 2 medications, that can cause bruising, Quetiapine Fumarate and Lorazepam, but it is rare. The facility does not have any surveillance cameras. R1’s responsible party reported the unexplained bruises could have been caused by facility staff. The facility General Manager reported that they spoke to memory care staff, and no one reported any falls or incidents regarding R1 that could explain the bruises. LPA toured the memory care unit and R1’s room. No obstacles or hazards were observed. A review of facility documents for August 2021 and September 2021 do not list R1 as having any accidents or injuries. It is unknown how R1 sustained their bruises. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. Regarding the allegation, the facility does not have adequate staffing to meet residents’ needs, the investigation revealed the following. It was alleged that the facility is understaffed in memory care and that the residents may not get their meals. No other specific details were provided concerning the lack of staff at the facility other than care would not be provided. At the time of the report the facility census was 70, with 22 of the residents residing in memory care. A review of the facility schedule shows the facility has an average of 25 care staff working each day including medication technicians, 13 for assisted living and 12 for memory care. For the months of August and September 2021 the Agency (CCL) received a total of 6 incident reports (LIC 624). None of the incident reports received give cause for concern for residents’ health and safety and none of them warranted a follow up visit. During the visit on January 27, 2022, LPA observed all the residents in memory care eating in the dining area. There have been no other reports that the facility does not have adequate staffing. Based on the information gathered through observation and a review of records, the allegation that the facility does not have adequate staffing to meet resident’s needs is deemed Unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report was provided.