complaint·March 3, 2026

LPA Amy Rodgers conducted an unannounced visit to deliver complaint findings and explained the purpose of the visit to Executive Director Angela Scott-Kapilof. The investigation included reviews of facility and outside records, and interviews with staff and outside sources. On 2/19/2026, the Department received a complaint alleging that facility staff were not following reporting requirements, specifically that management instructed staff not to document incidents in the internal reporting system. Department interviewed multiple staff regarding reporting practices. Staff consistently described documenting incidents in the electronic system, notifying the POA, and escalating concerns as needed. Staff did not report being instructed to withhold documentation. Department review of recent in-service trainings and staff interviews reveal management has been reinforcing guidance on objective, factual documentation. Department review of incident reports, progress notes, and related documents revealed no gaps or indicators of withheld information. LPA observations and outside source interviews showed no discrepancies between staff statements, written records, or required notifications. Based upon the information obtained during the investigation it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation occurred and is therefore UNSUBSTANTIATED. An exit interview was conducted with ED Angela Scott- Kapiloff and copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.