Complaint Investigation Report

During today's visit, LPA obtained the following documents: staff and resident rosters and documents from R1 to R4’s files. LPA interviewed Resident #9 (R9) to Resident #10 (R10). LPA re-interviewed R1, R2, and the Administrator.

The investigation revealed the following: in regard to the allegation "Staff are not properly intervening between residents’ altercations", it is alleged that R1 is being verbally harassed by R2 since June of 2025 with constant requests for favors, physical assistance, and money. It is also alleged that R2 also blocks R1's access to R1’s drawers and R2 makes loud noises when R1 is trying to sleep. R2 has also been observed in various stages of undress and has made unwanted sexual advances toward the R1. It is also alleged that R1 is sexually harassed by R3 and R4 by making unwanted sexual advances towards R1 since June 2025. R1 and three (3) out of ten (10) residents interviewed corroborated with the allegation but stated that inappropriate interactions were not reported to the staff. However, R1 and one (1) out of ten (10) residents stated that after the police visited the facility, R3 has stopped engaging in inappropriate interactions. R2 denied the allegations stating on not making unwanted sexual advances, verbally harassing R1, or asking to borrow money from R1. R3 and R4 interviewed both denied the allegations and stated never inappropriately touching nor making any inappropriate comments to R1 or other residents. LPA interviewed the Admin, and three (3) out of four (4) staff and stated that staff intervene, separate, and re-direct in residents’ altercations. The Administrator and three (3) out of four (4) staff interviewed did not witness R2, R3, or R4 verbally harass or make unwanted sexual advances towards R1. LPA received written documentation dated 8/21/2025 that R1 did not feel uncomfortable when interacting with R3 and the report indicated that R1 witnessed R3 touching another resident’s arm. Per administrator, R1 moved to a different room on 08/28/2025. Based on Special Incident Reports dated 8/28/2025 and 8/30/2025 indicates R4 being verbally aggressive and staff verbally warned R4. LPA interviewed the Administrator, three (3) out of four (4) staff are aware of R3 and R4 has made inappropriate comments and unwanted advances toward other residents. LPA received documentation dated 08/27/2025 in which it states to ensure resident safety, all management and staff are made aware of the incident regarding R3 who was placed on a 24-hour watch and provided additional staffing to ensure adequate supervision. To prevent further incidents, R3 has been lowered to 15-minute checks. Meeting with Management was also held with R3 and per Resident Care Director, R3 understands the severity of the situation. LPA requested documentation on staff training and Administrator provided in-service staff training conducted on 08/22/2025 on Abuse Reporting.