Complaint·May 13, 2026

The investigation revealed the following: Allegation: Staff did not provide adequate supervision to residents, resulting in resident being injured by another resident It is being reported that R1 was injured by another resident on 4/10/26. On 5/13/26, LPA Felisa Shirley reviewed the Unusual Incident/Injury Report, dated 4/10/26 reporting a small argument between R1 and another resident over a remote control for the television and R1 was injured by another resident. Per the incident report, dated 4/10/26, staff spoke to R1’s family member and was advised that R1’s behaviors can cause conflict with other residents. On 5/13/26, LPA Shirley reviewed R1’s Resident Assessment, dated 2/27/26. Per assessment, R1 has behavioral challenges and has inappropriate behaviors more than once a day. On 5/13/26, LPA Shirley toured this facility and went directly to R1’s room and observed R1 arguing with their assigned roommate. LPA attempted to convience R1 to leave the room for an interview. R1 did not leave. R1 refused to respond to LPA Shirley as R1 kept shouting in Spanish to her roommate. LPA interviewed staff 1 – staff 6(S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 7 out of 7 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not provide adequate supervision to residents, resulting in resident being injured by another resident,” therefore, the allegation is unsubstantiated. Allegation: Licensee does not ensure adequate staffing to meet the needs of residents It is being reported that a family member stated that it appears that Unit Five goes without supervision for hours. Family member stated that on 4/11/26 at 2:30pm, staff were not available in Unit Five. On 5/13/26, LPA Shirley reviewed staff’s April work schedule. During review of the schedule on 5/13/26, LPA observed that there are 3 work shifts. Per interview with S2 on 5/13/26, the work shifts are morning shift 6:30am to 2:30pm, evening shift 2:30pm to 10:30pm and Noc Shift 10:30pm to 6:30am. Per interview with S2, there are 2 caregivers per shift. On 5/13/26, LPA toured this facility at 2:25pm and observed a shift change within the unit. LPA Shirley observed that 2 caregivers were leaving and 2 caregivers were beginning their shift. LPA interviewed staff 1 – staff 6(S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 7 out of 7 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Licensee does not ensure adequate staffing to meet the needs of residents,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff did not keep resident's room clean It is being reported that a family member visited R1 on 4/11/26 and stated that it appeared that R1’s room had not been cleaned for some time. On 5/13/26, LPA Shirley reviewed the HouseKeeping Schedule and observed that all rooms are cleaned daily. The Housekeeping schedule begins at 6:30am thru 3pm, Monday thru Friday. On 5/13/26, the Maintenance Supervisor, stated that the schedule is the same for the weekends. Per interview on 5/13/26, S4 stated that all rooms are cleaned daily. On 5/13/26 at 11am, LPA Shirley conducted a tour of this facility and went directly to R1’s room and observed that the room was clean. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 5 out of 7 denied the allegation. One agreed and 1 was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not keep resident’s room clean,” therefore, the allegation is unsubstantiated. Allegation: Staff did not ensure resident was bathed It is being reported that on 4/11/26, a family member of R1 stated that she requested a staff member to bath R1 because it appeared that R1 had not been bathed. On 5/13/26, LPA Felisa Shirley reviewed R1’s shower schedule and observed that R1 is scheduled to be showered 2 times per week, on Tuesdays and Saturdays. LPA notes that 4/11/26 was on a Saturday. On 5/13/26 observed the staff’s 24-hour communication log for 4/11/26. Per the log, R1 refused to be showered. Per interview with S2 on 5/13/26, R1 hardly ever agrees to a shower. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 4 out of 7 denied the allegation. Three residents stated that they shower independently. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not ensure resident was bathed,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to Esperanza Naaktgeboren, Executive Director.