Complaint Investigation Report

The notice indicated the cause of eviction included behaviors by R1 that constituted “harassment or psychological abuse or causes mental suffering of an elder or dependent adult.” It was alleged if the behaviors rose to the level supporting an eviction notice, then the Administrator and staff, as mandated reporters, should have reported the abuse to Community Care Licensing (CCL), the local Long Term Care Ombudsman (LTCO) program, and local law enforcement using the SOC341 forms.

Interviews conducted with residents indicated that R1 discouraged them from sitting with preferred companions, interfered with group participation, and was observed repeatedly raising their voice and talking rudely to staff. Two residents stated R1 repeatedly entered another resident’s apartment uninvited to complain, as this resident was the resident council president, but was on Hospice. Multiple residents reported avoiding dining and activities due to R1, some observed other residents crying after interactions with R1, and two residents stated they would move out if R1 remained.

Resident Services Coordinator stated during interview R1 was overheard calling residents “dumb” or “not smart,” told some “you don’t belong,” and created a hostile environment. Staff interviewed stated they observed R1 yelling at residents and staff. On one occasion Staff 8 (S8) witnessed R1 throw a purse at a resident over a seating dispute on the bus. Staff noted residents with mild cognitive impairment were targeted and staff claim that some residents feared retaliation if they reported an incident and R1 found out about the report.

LPA obtained facility forms titled “Resident/Family Grievance report”. Twenty-two (22) forms were collected, all regarding R1. Eleven (11) of the twenty-two (22) forms document events between 07/03/2024 and 03/09/2025 of R1 refusing seating or activity participation to other residents, repeated unwanted phone calls to Resident 10 (R10), loud/banging noises affecting neighboring residents, demeaning comments to staff, misuse of laundry machines causing disruption in other residents using them, and multiple resident/staff grievances.

LPA received an Incident Report from 11/23/2024. The incident report documented a resident reporting to the facility that they were being harassed by R1, R1 was calling their cell phone repeatedly, and resident reported they felt very uncomfortable around R1 because they feel pressured or manipulated to join activities and meals. Continued on 9099-C