complaint·February 12, 2026

Allegation #1: Staff do not let residents come out of their rooms. The complaint alleged that the caregivers instructed them not to leave their rooms until they were called for meals and that staff would come to get them. On 02/12/26, the LPA arrived at this facility and observed three residents seated in the dining room. On the same day, the LPA interviewed the Administrator (A1), who denied the allegation and stated that all residents may leave their rooms if they choose. Additionally, on 02/12/26, the LPA interviewed two staff members, #1-2 (S1-S2), who both denied the allegation and explained that residents in wheelchairs are permitted to leave their rooms with staff assistance if they wish. The LPA also interviewed three residents, #1-3 (R1-R3), all of whom denied the allegation and stated that they leave their rooms at will. At the same time, the LPA spoke with one witness (W1), who also denied the allegation and mentioned that W1 visits the facility often and that R1 was always out of R1’s room. 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, therefore the allegation is unsubstantiated. Allegation #2: Staff yell at residents in care . The complaint alleged that staff raise their voices and yell at the residents. On 02/12/26, LPA interviewed the Administrator (A1), who denied the allegation and stated that staff were trained not to yell at residents, even if residents could not hear staff. Some staff members speak loudly because they believe the residents didn’t hear them, but not in a yelling tone. Report Continued on LIC9099C On 02/12/26, LPA interviewed three residents #1-3 (R1-R3), all of whom denied being yelled at by any staff. On the same day, LPA interviewed the witness (W1), who denied the allegation and stated that W1 visited the facility often. W1 would have noticed the yelling. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3: Staff does not provide proper toileting assistance to residents in care . The complaint alleged that staff failed to assist with toileting when called for help at night and stated, “You should go in my diaper.” On 02/12/26, LPA interviewed the Administrator (A1), who denied the allegation and said that some residents wear diapers and staff check residents at night to ensure they are changed. On 02/12/26, LPA Richard interviewed two staff members, #1-2 (S1-S2). Both denied ever failing to change a resident's diaper at night or assisting them out of bed. They also stated that they routinely check each resident at night and change residents' diapers three times a day, or earlier upon request. On 02/12/26, LPA interviewed three residents, #1-3 (R1-R3), all of whom denied the allegation and said they had been changed out of their diapers at night. R1 also stated that R1 likes how the staff treats R1. On 02/12/26, LPA interviewed one witness, W1, who denied any issue with staff assisting R1 daily. W1 confirmed that the staff provides proper toileting to R1. On 02/12/26, LPA interviewed one witness, W1, who denied any issue with staff assisting R1 daily. W1 confirmed that the staff provides proper toileting to R1. On 02/12/26, LPA reviewed facility notes and Unusual Incident Reports related to this allegation and found no documentation. On 02/12/26, LPA observed staff assisting residents throughout the day. Based on observations, interviews, and records review (s), the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the report was provided to the Administrator Vesna ILICH