complaint·February 23, 2026

Allegation: Staff left resident in a soiled diaper for an extended period of time Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues at the facility showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to allow staff to change his soiled brief on the following dates – on 08/02/22 R1 refused to allow staff to change his brief stating he wanted police to change him (R1 called 911); 08/21/22 R1 refused to allow his soiled brief to be removed by staff and preferring it to be left on the floor so police could see it (R1 called 911); 09/18/22 R1 refused to allow care team to change his soiled brief and blew a whistle when he was brought to the lobby disturbing other residents. On 10/09/22 and 10/12/22, R1 refused to allow staff to change his soiled brief and clothing, was verbally abusive to staff, attempted to kick staff and called 911 stating his care needs are not being met. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff left resident in a soiled diaper for an extended period of time was found to be unsubstantiated. Allegation: Staff did not respond to residents call button in a timely manner Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 has dementia who kept his call pendant light on 24/7. Staff (PD) witnessed R1 hit/scratch care staff, used foul language towards caregivers on 07/21/22, wouldn’t allow them to reset his call pendant, swung a broom at staff on 08/23/22 and would constantly call 911 stating staff was intentionally trying to harm, poison and kill him. On 09/17/22 R1 refused care team and would not allow them to reset his call pendant. ED stated R1 would constantly call 911 stating care staff was not attending to his needs. On 09/18/22 R1 refused to allow staff to change his brief and was brought to the lobby with whistle and created disturbance. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff did not respond to residents call button in a timely manner was found to be unsubstantiated. Continued on next page, LIC 9099C pg1 Allegation: Staff did not administer resident’s medication in a timely manner Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to take his insulin medication on 07/15/22, 07/27/22 and 10/15/22 as well as constantly arguing with staff regarding his insulin dosages. On 09/24/22, R1 exited his apartment and struck care staff, accusing staff of poisoning him. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not administer resident’s medication in a timely manner was found to be unsubstantiated. Allegation: Staff did not safeguard resident’s personal belongings Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated that R1 was first admitted at the facility in March 2022. ED stated R1 has dementia, paranoia and required a higher level of care. Review of R1’s documents did not show any theft or loss incident reports while R1 was in care at the facility. LPA also interviewed other residents (R2, R3) who stated that they did not have any missing items in their rooms. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not safeguard resident’s personal belongings was found to be unsubstantiated. Allegation: Staff are not providing adequate food service to residents Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 was first admitted at the facility in March 2022 and engaged in inappropriate behaviors towards staff and other residents from 05/08/22 until his eviction on 11/30/22. ED stated RP stated R1 wouldn’t allow the call light to be turned off, wouldn’t allow care staff to change his briefs, would argue with staff regarding his dosages of insulin, would yell racist and derogatory statements to a Black nurse, calling him “nigger”, would call 911 often, claiming he wasn’t receiving care. On 03/01/23, LPA interviewed R2 and R3 who stated they had no issues with food services at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not providing adequate food service to residents was found to be unsubstantiated. Continued on next page, LIC 9099C pg2 Allegation: Staff did not ensure residents’ plugs in room are not in disrepair Finding: Unsubstantiated On 12/09/22, LPA L Silveira conducted a walk through with ED at the facility of the following random bedrooms – B211, B219, B213, B318). LPA did not observe any electrical cover missing in the outlets nor wires sticking out of them during the walk through. ED stated R1 or his authorized representative did not report any electrical outlet issues with management while R1 was still residing at the facility. LPA also interviewed residents (R2, R3) who stated that they did not observe any missing electrical outlet covers or exposed electrical outlet wirings inside their apartments. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure residents’ plugs are not in disrepair was found to be unsubstantiated. Allegation: Unlawful eviction Finding: Unsubstantiated During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. ED notified R1 and RP on 06/26/22, that continued inappropriate behaviors towards staff, accusing them of intentionally harming R1 and calling 911 constantly were in violation of the facility’s rules regarding good conduct and that further incidences may result in the termination of R1’s admission agreement. On 10/13/22, R1 physically and verbally assaulted care staff in the lobby witnessed by other staff and management who called 911 and notified RP that R1 is no longer compatible at the community. On 11/01/22, ED stated they issued R1 and RP a 30-day eviction notice effective 11/30/22 for non-payment of basic services, violations of facility policies and incompatibility with other residents in care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of unlawful eviction was found to be unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.