complaint·August 7, 2025

[Continuation of LIC 9099] An interview conducted with Outside Source1 (OS1) revealed R1 disclosed that Staff1 (S1) was rough while they assisted them with a change of clothes and was told to “shut up”. OS1 could not determine if this was an isolated event or two events based on R1’s statement. OS1 also revealed R1 recently lost their partner of over 40 years and was relocated to their current placement and that R1 has made complaints at every prior placement. OS1 stated R1 could not provide a name of staff or date of the occurrence, just that it was a gentleman. An interview conducted with the Executive Director (ED) revealed being notified of the incident and was able to identify S1 by the staff schedule and gender. A review of S1’s records revealed no prior issues or incidents, and S1 has worked at the facility since 2020, prior to the change of ownership. An interview conducted with S1 revealed they had assisted R1 with a change of clothing (from pajamas to day clothes) but there was never an issue. The ED also revealed knowledge of R1’s history of complaints and a history of issues with R1 and male caregivers. In response, the ED assigned only female staff to assist R1 and has not had any issues since. An interview conducted with the RSD corroborated the ED's statements. Several attempts were made to contact R1’s Responsible Party (RP) and other facility staff for statements to no avail. However, a review of R1’s Department records revealed an interview with Outside Source 2 (OS2) conducted on May 13, 2025, that revealed R1 was not oriented and made inaccurate statements. Based on interviews and record reviews the above listed allegation was determined Unsubstantiated. This finding means the preponderance of evidence standard was not met. An exit interview was conducted with ED Watkins and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of the visit.