Complaint·May 19, 2025

The investigation revealed the following: Allegation 1: Staff did not accept resident back into care following hospitalization. It was alleged that Resident #1 was refused re-admission following hospitalization. On 11/04/2024 at 9:45 AM, LPA interviewed A1, who denied the allegation, stating that R1 needed more care but was not refused re-admission. Between 11:45 AM - 1:00 PM, LPA interviewed 5 staff members regarding the allegation: 2 of 5 staff denied the allegation. 3 of 5 staff were unaware of the situation. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 0 out of 7 residents confirmed the allegation. 2 out of 5 residents were unsure or unaware of the situation. 5 out of 7 residents denied the allegation. LPA reviewed records and did not observe any documentation to support the allegation. Based on interviews conducted an records reviewed there is no evidence to support the allegation, therefore the allegation is unsubstantiated. Allegation 2: Staff left residents in soiled diapers for an extended period of time. It was alleged that incontinent residents were not changed in a timely manner. On 11/04/2024 at 9:45 AM, LPA interviewed A1, who denied the allegation. Between 11:45 AM - 1:00 PM, LPA interviewed 5 out of 5 staff denied the allegation. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 4 out of 7 residents were independent and did not require incontinence care. 3 out of 7 residents who required incontinence care denied the allegation. LPA reviewed incontinence logs and observed documentation of care being provided every two hours. Based on interviews conducted an records reviewed there is no evidence to support the allegation, therefore the allegation is unsubstantiated . Report continues on LIC 9099-C Allegation 3: Staff did not treat residents with dignity or respect. It was alleged that staff mistreated residents. On 11/04/2024 at 9:45 AM, LPA interviewed Administrator (A1), who denied the allegation. Between 11:45 AM - 1:00 PM, LPA interviewed 5 staff: 4 out of 5 staff denied the allegation. 1 out of 5 staff acknowledged witnessing mistreatment. Between 10:00 AM - 11:30 AM, LPA interviewed 7 residents: 4 out 7 residents confirmed the allegation. 3 out of 7 residents denied the allegation. LPA reviewed records but did not observe documentation supporting the allegation. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be UNSUBSTANTIATED. No citations were issued for this complaint. An exit interview was conducted, and a hard copy of this Complaint Investigation Report was provided to Teresa Pascual, Wellness Director.