Complaint Investigation Report

Administrators indicated the reasons listed on the eviction letter were true and have witnesses to confirm the dates of occurrences. Per the administrators, they have tried working with R1 and had a behavioral contract in place. However, R1’s conduct has not improved and has escalated in severity. Some staff interviewed have observed R1 being verbally aggressive and harassing others. LPA obtained and reviewed the 30-day eviction letter that was issued to R1 on 6/23/25. The eviction letter included the specific facts for the cause of eviction. The residents interviewed today have not received any eviction notices.

Allegation - Facility did not prevent resident from being harassed by other residents. It is alleged that the administrators are not preventing R1 from being harassed by the 4 female residents. Administrators were not aware of R1 being harassed by other residents until recent. Administrators stated that staff will intervene immediately if they observe any inappropriate behaviors or altercations. Administrators will address any issues between residents individually and will not disclose to other residents what is being done. Staff interviewed stated that they are always monitoring residents and ensuring their safety. Staff will try to de-escalate any situations amongst residents when they need to and ask residents to stop the inappropriate talks. Ten out of ten residents stated that they have seen staff intervene right away if there are any issues among residents.

Allegation - Facility failed to maintain resident's citizenship documents. It is alleged that the administrator was safeguarding R1’s citizenship document, and when asked, the administrator either lost or misplaced it. LPA interviewed the administrators, who both stated they did not recall R1 asking them to safeguard any documents. Both stated that R1 had requested it right before moving out; however, administrators informed R1 that they did not keep any documents of such in their office and that they do not have a safe as alleged. Administrators stated that they would have documented it on their safeguarding/valuable form if they kept it. Ten out of ten residents have not asked the administrators to keep anything for them. Residents stated they stored their belongings and valuables in their rooms.

Allegation - Staff does not respond to the resident’s call button in a timely manner. It is alleged that staff did not respond to a fall for up to 2 hours due to staff not available. Administrators stated that every room is equipped with pull cords by their bedside and in the bathrooms. When a resident pulls the cord, it alerts the front desk, and the receptionist will respond to the call. The receptionist will call for a staff to assist the resident right away. Caregivers have walkie-talkies that they carry throughout their shifts. Staff interviewed stated they respond to calls right away and do room checks at least every 2 hours. LPA interviewed ten residents, and all the residents stated that the staff assist them right away when they call for them.