complaint·February 4, 2026

The investigation consisted of the following: On 01/13/2026, Witness 1 (W1) was interviewed. On 01/14/2026, interviews were conducted, and records were reviewed. Staff 1 (S1) to Staff 4 (S4), Witness 2 (W2) to Witness 3 (W3), and Resident 1 (R1) were interviewed. Facility records were reviewed which consisted of Employee Roster; Resident Roster dated 01/14/2026; 2025 In-Service Staff Trainings which consisted of Hoyer Lift Training and Gait Belt Transferring dated 01/28/2025, Resident Rights dated 11/15/2025, Gait Belt and Proper Body Mechanics Training dated 12/01/2025, Resident Rights dated 12/19/2025, and Transferring and Gait Belt Transfers dated 12/23/2025. R1’s records were reviewed which consisted of Physicians Report dated 12/04/2023; Resident Appraisal dated 01/13/2026; Identification And Emergency Information dated 07/07/2024; and Service Assessment Form dated 01/13/2026. Investigation revealed the following: Allegation: “Staff improperly transferred resident resulting in injury”, it is being alleged that staff improperly transferred R1 resulting in their right knee being injured. Interviews conducted with R1 revealed the following: R1 denied the allegation, furthermore, R1 indicated that their right knee was not injured and their right knee does not hurt. Interviews conducted with W1 to W3 revealed the following: 3 out of 3 witnesses denied the allegation. Interviews conducted with W1 revealed the following: W1 indicated that on 01/08/2026, they did not observe any injuries or bruises on R1’s right knee, furthermore, W1 states that the next day a Physical Therapist tested R1’s right knee and did not observe any injuries on R1’s right knee. Interviews conducted with S1 to S4 revealed the following: 4 out of 4 staff denied the allegation. R1’s records reviewed revealed the following: there are no Unusual Incident Reports nor Medical Records indicated that R1’s right knee was injured. In-Service Staff Trainings revealed the following: staff were training on Gait Belt transfers throughout the year of 2025 for example, Gait Belt Transferring dated 01/28/2025, Gait Belt and Proper Body Mechanics Training dated 12/01/2025, Transferring and Gait Belt Transfers dated 12/23/2025. Based on interviews and records reviewed this allegation is unsubstantiated. 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 unsubstantiated. Allegation: “Staff do not treat resident with dignity and respect”, it is being alleged that during R1’s transfer on 01/06/2026 a staff laughed at R1. Interviews conducted with R1 revealed the following: R1 agreed with the allegation, additionally, R1 indicates that S4 laughed at them during the transfer and stated that Staff 3 (S3) was present during the transfer. Interviews conducted with S3 and S4 revealed the following: S3 and S4 denied the allegation, furthermore, S3 and S4 indicated that they assisted R1 with the transfer on 01/06/2026. Interviews conducted with W2 revealed the following: W2 denied the allegation, furthermore, W2 indicated that they were present during R1’s Service Assessment on 01/13/2026 and R1 indicated that staff did not laugh at them and that they are overall satisfied with the facility. Service Assessment Form dated 01/13/2026 revealed the following: “Resident states they love it here. They decline all allegations made with wellbe.” People present during the meeting were R1, S1, S2, W2, W3, R1’s family, and Welbe Health. In-Service Staff Trainings revealed the following: staff were trained on Resident Rights on 11/15/2025 and 12/19/2025. Based on interviews and records reviewed this allegation is unsubstantiated. 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 unsubstantiated. No deficiencies were provided. An exit interview was conducted, and a copy of this report was left with the Administrator, Heather Argueta and Resident Care Coordinator, Corina Kahl.