Complaint·January 15, 2026

R1 stated the Administrator was in denial at first but many people knew what happened so they could not deny it anymore. R1 stated staff had gloves on and were taking the box out. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. On 01/15/2026 LPA Jeffries conducted an interview with Administrator who stated,On 01/15/2026 LPA Jeffries conducted an interview with Administrator, Lisa Gerr, who stated R2 did have observed elevated behaviors and were addressed by physician days after two incidents pertaining to this complaint. LPA Jeffries noted on prior visit to the facility on 05/21/2026 that facility was short on staff and was addressed in a case management visit report on 05/21/2026. Based on the information obtained, the allegation is Substantiated at this time. On the allegation: Due to lack of supervision, resident physically assaulted resident. It was alleged a resident came into R1’s room at night, ripped the blankets off R1 and grabbed R1’s arms. Staff interviewed stated there was an incident one night where Resident 2 (R2) wandered into R1’s room. Administrator stated R2 had experienced a change in demeanor, with wandering, going into other resident’s rooms, moving a shirt from room to room. Administrator stated they had informed R2’s physician and responsible parties, and watched R2 more closely with hourly checks. Administrator stated R2 had become more aggressive to R1. Administrator stated R1’s RP informed them a resident came into the room and “attacked” R1. Administrator stated they were no injuries, and they gave R1 a lock for their door. Administrator stated the same evening R2 gave unwanted advanced to a visitor, and the Administrator tried to redirect them, but R2 gave them an angry look. Administrator stated they had another appointment scheduled with R2’s physician on 5/6/2025 due to the increased behaviors. Administrator stated they offered R1 anything they needed to feel safe aside from the lock on the door. When interviewed, R1 stated a resident was ripping blankets out of their hand, and was grabbing them. R1 confirmed the Administrator got them a key for their door, but someone could come through the bathroom. R1 stated they were told R2 also went into another resident’s room and was standing over their bed staring at them. LPA reviewed text messages between the Administrator and RP discussing the incident. The messages show RP stating they think the resident who pooped in the box may be the same one that came into R1’s room at night. LPA reviewed message from Administrator, that discusses the resident R1 was concerned about “who had been coming into [R1’s] room.” The message states the resident’s doctor has been contacted and they do not expect any more issues, and in the meantime staff will keep a close eye on the resident. Based on the information obtained, the allegation is Substantiated at this time. The Administrator gave their next available time at the facility. During interviews, R1 indicated they believed the Administrator was “brainwashing” them to turn against their RP. R1 also stated they had panic attacks. R1 stated they had just had a medical treatment that takes a toll on them, and then Administrator explained aspects of the lease or admission agreement. When R1 put on glasses and read the documents, they were different and they felt the Administrator had “lied.” R1 stated the Administrator made them upset and they ended up in the hospital with atrial fibrillation. R1 was unable to be interviewed any further. RP stated although R1 did not have dementia, they felt R1’s medical treatments were affecting some parts of R1’s memory. Staff interviewed confirmed R1 had memory issues, and in the staff’s opinion, was confused, very anxious, could get “rattled.” 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 at this time. The Administrator is reminded to conduct themselves in an appropriate manner at all times that ensures residents are treated with respect. Exit interview conducted. Copy of report issued at the time of the visit.