S1 admitted that there have been times they have provided bathing and toileting care without wearing gloves, stating this occurred when the correct glove size was not immediately available. S1 also admitted they were not wearing gloves while plating food for residents in memory care until they were instructed to do so during a recent training.

A review of S1’s personnel file revealed that they were counseled in February 2026 for not properly wearing gloves during resident care. Records further show that S1 received additional training in March 2026 from the Health and Wellness Director regarding proper glove use. The Administrator confirmed they were aware there had been issues regarding S1’s glove use but did not recall whether formal disciplinary action had been taken.

The facility’s Plan of Operation states that all staff must maintain infection control practices, including hand hygiene and the use of gloves as protective barriers to prevent infection transmission. It further specifies that personal protective equipment (PPE) must be used during direct care tasks, including bathing and incontinence care. Staff confirmed they receive online video training that includes instruction on when PPE is required.

Based on all interviews conducted and documents obtained, S1 did not wear gloves as required and at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.

Multiple witnesses reported they had informed the Administrator and the Health and Wellness Director about these incidents involving S1 but did not feel the concerns were addressed.

A review of S1’s personnel file revealed a typed note indicating that S1 does not appropriately redirect residents, does not do so professionally, speaks to residents in a manner perceived as mean, and does not remain calm. The note states that S1 needs additional training. No disciplinary action or follow-up training was documented. The Administrator stated they were unaware of the note until reviewing the file during this investigation. The Administrator explained that minor issues are typically handled by department managers, and they only become involved if issues escalate or reoccur. The Administrator recalled that when S1 first started, some residents in assisted living had concerns about S1 but not regarding the way they spoke to them or treated them. The Administrator recalls the previous Health and Wellness Director briefly mentioned something about the way S1 spoke to the residents but understood that they were handling it. The Administrator does not recall further concerns being brought to their attention.

Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred.

Interviews revealed multiple instances of inappropriate communication by S1. One witness observed S1 sitting in the memory care unit looking at their personal phone while a resident repeatedly asked S1 if they could use their phone to call their spouse. The witness reported that S1 responded in a firm tone, stating to the resident that their spouse was dead and therefore could not call them.

On another occasion, a witness observed a resident stating they wanted to go home. The witness reported that S1 got close to the resident’s face and raised their voice, stating that the resident could not go home because the house was being fumigated and they would die. The witness clarified that S1’s tone was not raised for the resident to hear because this resident was not hard of hearing, but that S1’s voice was aggressive in nature, and after the interaction the resident became visibly anxious and tearful.

A different witness reported an incident in which a resident attempted to get up from their chair during a meal to use the restroom. S1 reportedly told the resident, in an aggressive tone, that they could not go because they had not finished eating and that they should go to the bathroom in their brief instead.

During interview, S1 acknowledged that staff and residents have told them they sound aggressive when they speak, and they said they do not know how to correct this. S1 stated they used to tell residents the truth about situations such as informing them that their spouse had died, but denied intentionally being aggressive.

Witnesses also stated they have observed S1 grab residents in a rough manner. Witnesses additionally reported an incident in March 2026 involving Resident #1 (R1). Staff found R1 sitting on the floor in the memory care kitchen area. S1 was reportedly on their personal phone in the dining room in a position where they should have been able to observe R1. When staff checked on R1, the resident was unresponsive to verbal cues. Staff asked S1 to assist them with R1 and when S1 came over they kicked R1’s leg, causing the resident to say “ow.”

(Continued on LIC9099-C)