complaint·October 3, 2025

1 out of 7 residents interviewed reported that the washing machines didn't work right and leaked. 5 out of 5 staff interviewed reported that there have been no issues with the washing machines and no one reported any issues to staff. It was reported that the door next to the dining room would not open and close properly and would remain open. 1 out of 7 residents reported that the door would always stay open and would not close all the way and would remain partially opened. 5 out of 5 staff reported they were unaware with any issues regarding the door next to the dining room. The Administrator reported that the door can always be used to exit but closes by itself and then is locked and cannot be opened without a key from the outside. The Maintenance Director reported that the door is functioning properly and there have been no reports about it not working properly. LPA inspected and used the door. LPA observed the door functions properly, after someone exits, it closes by itself and is locked to the outside. It was reported that the carpet in the dining room was torn and a trip hazard. The Administrator reported that the carpet was replaced in the dining room. The Administrator reported that the carpet had normal wear and tear and had been scheduled to replaced but was unaware of any trip hazards. LPA interviewed 6 out of 7 residents who reported they never noticed any tears or rips in the carpet. 5 out of 5 staff interviewed reported the carpet was old but was not a trip hazard. The maintenance director reported that flooring is replaced as needed prior to it becoming a safety hazard. LPA observed that all of the flooring in the facility during the visit was in good repair. LPA observed no deficiencies regarding the physical plant during the visit. Based on the evidence gathered the allegation is deemed unsubstantiated. 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, The investigation into the allegation, staff were verbally harassing resident, revealed the following. It was reported that 2 kitchen staff members and the Administrator verbally harassed Resident 1 (R1). R1 reported they were yelled at and spoken to in an inappropriate manner. Staff member 1 and Staff member 2 denied the allegations. The Administrator denied the allegations. No details as to the time and date of the incident were provided. 5 out of 5 staff members interviewed reported they have never witnessed any staff speaking inappropriately to any resident. 7 out of 7 residents interviewed reported they have never witnessed or been spoken to in an inappropriate manner by staff. Based on the evidence gathered the allegation is deemed unsubstantiated. 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, The investigation into the allegation, facility does not provide a safe environment for residents, revealed the following. It was reported that the door by the kitchen, which leads to the parking lot is left open at night and people who do not live at the facility come into the facility and pose a threat to residents in care. 5 out of 5 staff interviewed reported the door is always closed and no one who isn't a resident has come into the facility though the door. 1 out of 7 residents interviewed reported that they saw someone who did not live at the facility come in through the door at night. No specific details were provided in this report. 6 out of 7 residents reported they have never seen anyone other than residents use the door. The Administrator reported that the door is working properly and a key is required to open the door from the outside. The Administrator reported that all night staff are aware and have been trained that all doors are required to closed and locked to the outside, except during normal business hours. LPA observed the door functions properly, after someone exits, it closes by itself and is locked to the outside .A review of incident reports from the facility for the months of August 2025 and September 2025 do not show any incidents that are related to the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated. 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. An exit interview was conducted with the Administrator and a copy of the report provided.