complaint·September 4, 2025

Interview with the administrator at 2:35 p.m. on 07/10/25 revealed they spoke with R1 after hearing R2’s report. R1 claimed they did not remember anything. Interview with Staff #1 (S1) at 3:15 p.m. on 07/10/25 revealed R1 and R2 were friends before R2 reported harassment. Interview with Staff #2 (S2) at 3:30 p.m. on 07/10/25 revealed R2 was intoxicated and said sexual words to R1. S2 stated they separated the R1 and R2 and reprimanded R1 for the incident. Based on interviews, although the allegation may be valid, there is insufficient evidence to provide its validity. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Facility admitted an unsuitable resident" it was alleged a resident slept outside on the smoking area for two (02) nights and was not suitable for the facility. Record review revealed the facility sent two (02) incident reports regarding R3’s behavior. The first report from 07/01/25 revealed Staff #3 (S3) found R3 lying outside and refusing care. The second report from 07/02/25 revealed R3 was admitted to the hospital on a 5150 hold. Interview with S3 at 3:00 p.m. on 07/10/25 revealed R3 spent two nights outside. Staff supervised R3 at least every 2 hours and brought them food, water, and medications as needed. Interview with S1 confirmed staff supervised R3 every thirty (30) minutes and eventually called the paramedics since it was 90 degrees outside. Interview with the administrator revealed Resident #3 (R3) was admitted after a full preadmission appraisal and discussion with R3’s social workers. R3 was part of a street outreach program and needed help adjusting to sheltered life. Review of R3’s care plan revealed they needed assistance “deconditioning”. Review of R3’s medical assessment showed they were appropriate for the facility and did not need a higher level of care. Based on interviews and record review, R3 was suitable for the facility, and staff appropriately handled R3’s refusal of care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff provided inadequate bathing assistance" it was alleged staff did not provide shower assistance to Resident #4 (R4) for over a month. Record review of the shower schedule revealed staff were scheduled to assist R4 on Monday and Thursday afternoons. Interview with R4 today at 4:45 p.m. revealed they have received sufficient assistance with bathing since arriving in June 2025. R4 appeared to be neat and well-groomed today. Interview with S1 confirmed R4 received baths twice a week from staff and did not refuse bathing assistance. S2 and S3 confirmed R4 has regularly received assistance with bathing. Based on observations, interviews, and record review, staff provided adequate bathing assistance to R4. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.