Complaint Investigation Report

During the interview with R1 on 12/04/25, R1 was asked about the identity of the unknown male who allegedly intimidated them. R1 indicated they did not know what male was being referenced and did not provide any explanation related to the allegation. When asked whether they had any safety concerns within the community and/or with staff, R1 stated they did not. They reported enjoying living in the community, participating in games and activities, and feeling safe in the facility. They did note, however, that some staff lack appropriate training for their roles. Interviews with five (5) of (6) six residents indicated they had never been intimidated by staff and had never observed staff intimidating other residents.

Based on the information obtained during the course of this investigation, there is insufficient evidence to support the allegation Administrator intimidated resident. 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 deemed UNSUBSTANTIATED at this time.

Staff allowed for a resident to expose themself indecently to others

It was alleged that s taff allowed a resident to expose themself indecently to others. To investigate the allegations on 8/13/25, LPA Smith conducted a 10-day visit at which time LPA Smith requested documents relevant to the investigation, interviewed with the administrator and three (3) residents. Interview with S2 reveal was assisting resident #3 (R3) in their room when resident #2 (R2) opened door by accident and immediately apologized for opening the wrong door. Staff revealed that R3 did not get into R3 bed and/or expose themself indecently to others nor did R3 scream and run out of their room. Interview with administrator revealed follow-up was conducted with R2 who admitted to having a beverage containing alcohol prior to coming back to the facility and heading to their room. Interview with R2 revealed that they opened the wrong door on the way to their room but denied getting into R3’s bed and denied exposing themselves indecently to anyone. LPA was unable to interview R3 as residents no longer reside at the facility.

Based on the information obtained during course of investigation, there is insufficient evidence to support the allegation. 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 deemed UNSUBSTANTIATED at this time.