complaint·March 4, 2026

Interviews and record review reflected that on 11/14/2025, S1 was assisting R1 in the restroom and was overheard stating, “Why are you so big?” Four (4) staff members were interviewed. Two (2) staff reported they have never observed staff speak inappropriately to any residents. One (1) staff member who was aware of the incident believed the comment was inappropriate. Another staff member who was aware of the incident stated the comment did not appear to be directed at R1 but rather was said aloud as a general remark. R1 was checked following the incident. Due to hearing impairment, R1 did not indicate awareness that any inappropriate comment had been made. An internal investigation was conducted from 11/17 to 11/19/2025 and included interviews with four (4) staff members and R1.The investigation found insufficient evidence to substantiate that S1 was verbally abusive toward R1.The evidence indicated that the comment regarding weight was made to a co-worker and not directed at R1. Per interview with S1, the comment “heavy” was stated because usually R1 assist with their mobility however, during the time R1 was not being supported by any device therefore, making the transfer “heavy” than usual . R1 did not demonstrate awareness of the comment or any resulting harm. LPA reviewed the internal investigation findings with Quality Assurance Specialist (QAS) Brown, who agreed the comment did not appear to be directed at R1 and that R1 showed no awareness of or harm from the remark. Furthermore, Brown did not express any concerns for staff saying anything inappropriate to any residents at this time. LPA attempted to interview R1, but LPA was not able to successfully communicate with R1 during the investigation. Based on the information obtained during the investigation, even though S1 made a remark regarding R1’s weight it was not intended to be negative and misconstrued due to language barrier. S1 was remorseful of the situation and agreed to additional training. Therefore, the above allegation “Staff spoke to resident in an inappropriate manner” is deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report issued.