complaint·January 7, 2026

The investigation revealed the following: Allegation: Staff did not assist resident with ambulating It was alleged that facility staff failed to assist a resident for days at a time and that prior to 12/21/2025 the resident had not been out of bed since 12/16/2025. It was also alleged that staff told resident they cannot get the resident out of bed. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated caregivers routinely check on residents in the morning and offer assistance getting out of bed. A1 stated that residents are assisted based on their willingness and ability to transfer safely. Additional caregivers assist when a two- or three-person transfer is required, and the nurse is contacted if a resident is in pain. A1 acknowledged awareness of a R10 remaining in bed prior to 12/21/2025 but denied that any caregiver refused to assist a resident without reason. On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 9 of 10 staff denied the allegation and stated resident who need assistance with ambulation will help upon request and or following the directives of the residents care plan. 1 of 10 staff did not confirm nor deny the allegation and stated due to R10 have a neck injury it was advised resident be on bed rest for 3-4 days. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 1 of 10 residents confirmed the allegation and stated they are suppose to get help from staff when they want to get out of bed but that doesn't happen ; staff would take too long to assist them so they would get themselves out of bed. 9 of 10 residents denied the allegation. 3 of 9 residents stated staff will come by in the morning to assist with transferring, while 6 of 9 residents independently get themselves out of bed. On 01/07/2026 between the hours of 8:40am - 8:45am, LPA conducted a records review and observed the following: the LIC 625 Appraisal/Needs & Service Plan (dated 09/23/2025) stated for R10 one caregiver reported that two of caregivers are not able to transfer R10 due to an unintentional fall as a result of the resident's weight. Caregivers noted R10 needs at least 3 caregivers to assist him with his ADLs and transfer. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Investigation findings continues on LIC 9099-C Allegation; Staff handled resident in a rough manner It was alleged that staff attempted to transfer a resident from their bed to their wheelchair by pulling their arms to raise themselves from the bed which the resident reported that a male caregiver pulled the resident up too quickly by their arms and hurt the residents neck. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated that staff are trained to use appropriate transfer techniques based on resident ability. A1 stated that staff are instructed to contact the nurse if a resident appears uncomfortable or in pain and to complete a report if a resident reports injury. A1 stated they were not aware of any caregiver handling a resident roughly during a transfer. On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 10 of 10 staff denied the allegation and expressed not handling the resident in a rough manner. On 12/29/2025 , between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 10 of 10 residents denied the allegation and stated never experiencing being handle in a rough manner by staff. On 01/07/2026 , between the hours of 9:20am - 9:25am, LPA conducted a records review and observed the following: LPA did not observe any incidents reports nor resident notes in regards to this allegation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Investigation findings continues on LIC 9099-C Allegation : Staff do not assist resident with arranging transportation It was alleged that staff do not assist a resident with scheduling their ACCESS transportation services, resulting in the resident being unable to attend church services. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated that the facility assists residents with scheduling ACCESS transportation upon request. A1 stated that some residents schedule their own transportation. A1 reported that transportation issues involving R10 occurred due to scheduling errors and missed phone calls, not staff inaction. A1 stated that if ACCESS cancels transportation, staff notify the resident and offer to reschedule. On 12/29/2025 between the hours of 9:43am -4:00pm, the LPA interviewed 10 staff regarding the allegation. 8 of 10 staff denied the allegation and stated resident or the resident's family will arrange their own transportation but the front desk will assist with arranging transportation for the residents upon request. 2 of 10 staff were unaware of the allegation. 2 of the 2 staff stated not having any knowledge of residents transportation being delayed and or canceled. On 12/29/2025 , between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 8 of 10 residents denied the allegation and states making arrangements for transportation themselves. 2 of 10 residents did not confirm nor deny the allegation. 1 of 2 residents stated not knowing how to setting up rides or transportation but would like to someone who would help them get more information on how to do so in regards to this matter. While the other 1 of 2 resident stated this allegation does not apply at all due to them never trying to go somewhere. On 01/07/2026 , between the hours of 9:20am - 9:25am, LPA conducted a records review and observed the following: LPA did not observe any reports and or notes in regards to this allegation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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 cited for the allegations above. An exit interview was conducted with Catherine Dacara (Assistant Administrator) & a copy of this report is provided.