Complaint·December 17, 2025

Allegation: Staff yell at residents in care. The investigation into this allegation consisted of observation, interviews and record reviews. When staff were interviewed, they admitted that staff sometimes get into “heated arguments” with residents. Staff explained that during these arguments, they raise their voices at residents to “get their attention.” S2 also admitted that he has seen staff yell or raise their voices at residents. He said he believes this behavior is not appropriate. S2 stated that when he sees this happen, he gives staff verbal reminders about how to speak to residents in a respectful way. However, he also admitted that he has not documented any of these in-service trainings. S2 said that staff need to improve how they communicate with residents and that they need more training. Interviews with witnesses confirmed hearing yelling coming from this facility at times but cannot confirm if the yelling is from by staff or residents. Staff interviews confirmed that yelling or raising voices at residents does happen. Staff do not see it as a problem, while S2 does. S2’s lack of documentation shows that the facility has not been keeping proper records of training or corrective actions. This supports the concern that staff are not consistently using appropriate communication with residents. Based on all the information gathered, there is enough evidence to show that staff have yelled at residents, therefore, allegations are substantiated *************************************************** Allegation: Staff did not provide adequate supervision to residents in care. An investigation was completed after a complaint was made that staff were not giving residents proper supervision. Interviews were done with the S2 and staff, and resident records were reviewed. During an interview, S2 said he was not aware of any residents defecating in the backyard or in public. He did say that one resident (R1) has a history of inappropriate defecation inside their room, but not outside the facility. However, S2 also admitted that about two weeks ago, another resident (R2) urinated in a street gutter in front of the facility without supervision. S2 learned about this incident from a neighbor, who verbally reported it to S2. S2 further admitted that R2 eloped from the facility about 2–3 days ago. He explained that staff (S1) saw R2 walking down the street but did not follow R2. Instead, staff called 911. Verbal redirection made to R2 was unsuccessful. A review of R2’s records showed that R2 is assessed as a resident who should not leave the facility without staff assistance. This means staff were expected to closely supervise R2 to prevent them from leaving on their own. During an interview with staff (S1), S1 confirmed that R1 has a pattern of inappropriate defecation, including making messes in their room and bathroom. S1 also stated that R1 used to defecate in the backyard in the past. S1 also stated that R2 eloped and she stated she instructed another resident (R4) to follow R2. Interview with witnesses confirmed that there was one instance, about 2 to 3 weeks ago, where a witness observed a person urinating on the street gutter. Witness confirmed that the mentioned resident was unsupervised. The witness’s description of the mentioned the resident is consistent with a current resident in care. Based on the evidence gathered, the allegation that staff did not provide adequate supervision to residents in care is substantiated . These incidents show that staff did not provide the level of supervision needed to keep residents safe and prevent unsafe behaviors in the community. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with S2 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.