complaint·March 10, 2026

Allegations: “Staff did not provide resident with assistance in a timely manner” and “Staff did not treat resident with respect” It was reported that Resident #1 (R1) was left unassisted on the evening of 01/21/2026 which resulted in R1 spending the night in their wheelchair. It was also alleged that on 12/18/2025, overnight staff mocked R1 and did not provide them with assistance. Interview with R1 revealed that at approximately 6:25PM on 01/21/2026, they had dinner and asked who would be assisting them with preparing for bed. They were informed that Staff #1 (S1) would assist; however, S1 never arrived. At approximately 9:25PM, R1 called the facility phone and S1 told them they would be assisted shortly. Assistance did not occur, and when R1 called again, there was no answer. R1 remained in their wheelchair throughout the night and was afraid to fall asleep until Staff #2 (S2) found them the following morning. R1 stated they did not use their call button that night. R1 also reported that they enjoy living at the facility, that the Administrators address concerns promptly, and that staff generally treat them well. R1 denied experiencing disrespect or mocking from staff and expressed a preference for certain caregivers. S1 reported that R1 typically returns from Dialysis between 6PM and 6:30PM, waits about an hour before requesting dinner due to post-treatment weakness, and then receives assistance with bedtime preparation around 8:30PM. On 01/21/2026, S1 stated that R1 refused assistance and requested a specific caregiver who was not scheduled. S1 reported offering assistance multiple times, but R1 allegedly became angry and yelled at S1 to leave. When S2 arrived for their shift, S1 informed them of R1’s refusals. S2 attempted to assist but was also unsuccessful. S2 reported checking on R1 every two (2) hours and leaving R1’s door slightly ajar to maintain visual monitoring due to R1’s agitation and yelling. S2 observed R1 to sleep and watch TV in their wheelchair throughout the night. S2 stated that R1 used their call button once and also called the facility phone between 4AM and 5AM requesting restroom assistance. Additional staff interviews indicated that R1 frequently refuses assistance and requests specific caregivers who may not be available, though staff attempt to accommodate these preferences. Staff denied witnessing or engaging in disrespectful behavior toward residents. Report Continued on LIC 9099-C A review of the facility’s internal incident reports revealed four (4) additional occurrences involving R1’s refusals and aggressive behavior toward staff. R1 had also made a secondary claim of not receiving assistance overnight; however, the facility’s investigation determined that staff had provided care. Facility service logs for 01/21/2026 to 01/22/2026 documented that R1 received “Aid Incidentals” at 6:41PM, Quality Check at 7:41PM, Meal Service at 7:45PM, Quality Check at 12:38AM, and Incontinent Care at 9:02AM. Staff reported they were unable to scan the QR code in R1’s room to confirm additional Quality Checks due to R1’s refusals. Although S2’s assistance between 4AM and 5AM was not logged, an Unusual Incident Report documented that R1 used their call button at 4:30AM requesting assistance. R1’s Physician’s Report dated 02/20/2025 documented a diagnosis of end stage renal disease requiring Dialysis treatment. At that time, R1 was not noted to be disoriented, aggressive, or depressed and was able to follow instructions and communicate their needs. Individual Service Place (ISP) dated 08/01/2025 later documented R1 additional diagnoses of depression and an unspecified mental disorder. The ISP noted that R1 has difficulty remembering and using information, experiences some difficulty in new situations, and sometimes demonstrates impaired judgment. R1 also exhibited agitation, disruptive or aggressive behavior, and emotional states that created frequent difficulties with others. The ISP emphasized that maintaining open communication with R1 is essential to establishing trust, safety, comfort, and social engagement. Based on interviews and record review, although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.