complaint·March 9, 2026

The investigation consisted of the following: Allegation: Staff does not treat residents with dignity and respect It was alleged that facility staff does not treat residents with dignity and respect. During breakfast time one of the younger staff workers spoke to the resident in a disrespectful manner. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and indicated that the facility has not recently received any complaints regarding how staff speak to residents. A1 stated having no knowledge of any incidents where staff spoke to residents in a disrespectful manner. A1 mentioned if a staff member speaks disrespectfully to a resident, the facility would first arrange for a 1-on-1 meeting with staff, second talk to the resident to listen to their concern, third provide training to all staff, fourth take disciplinary action, and fifth remove the staff from that unit as a change of face. On 02/19/2026 between the hours of 9:26am - 11:43am, LPA conducted 5 staff interviews regarding the allegation. 5 of 5 staff denied the allegation and indicated they have not received complaints from residents or their families about how staff speak to residents, are not aware of any incidents where staff spoke to residents in a disrespectful manner, and would report such incidents to the Administrator and complete an incident report. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 3 of 10 residents confirmed the allegation and indicated staff do not speak to them nicely all the time, staff have spoken to them in a rude or disrespectful way a few times or every once in a blue moon or staff do not treat them with respect all the time, and they have witnessed or heard staff speak rudely to other residents. Of the 3 residents who confirmed the allegation ;  1 of the residents indicated they have seen staff speak rudely to other residents. 7 of 10 residents denied the allegation and indicated staff speak to them nicely, no staff member has ever spoken to them in a rude or disrespectful way, staff treat them with respect, and they have not seen staff speak rudely to other residents. On 02/27/2026, between the hours of 2:25pm - 2:30pm, The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes that alleged a staff spoke to a resident in a disrespectful manner. Unsubstantiated: 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. Allegation: Staff do not accord resident privacy It was alleged that facility staff do not accord residents privacy. A staff worker came into the resident's room without knocking, used their key, and walked right in. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and disclosed the facility's policy about entering residents' rooms requires staff to knock before entering, identify themselves, asking for permission first, and explain the purpose of entering the room. If the resident doesn't want staff to enter, then staff has to respect that. A1 stated always knocks before entering a resident's room all the time and identifying herself. A1 indicated never receiving any complaints about staff entering residents' rooms without knocking. A1 mentioned staff has received training on respecting residents' privacy. On 02/19/2026 between the hours of 9:26am -11:43am, LPA conducted 5 staff interviews regarding the allegation. 1 of 5 staff confirmed the allegation and disclosed entering a resident's room without knocking first which resident have made complaints about. 4 of 5 staff denied the allegation and indicated the facility's policy about entering residents' rooms is to always knock first before going in, they knock before entering a resident's room, they have not entered a resident's room without knocking first, and they have received training on respecting residents' privacy. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 4 of 10 residents confirmed the allegation and indicated staff do not knock on their door before coming into their room or only occasionally, staff have walked into their room without knocking, and they do not feel they have privacy in their room. Of the four (4) residents who confirmed the allegation, one (1) resident reported having to place a 160 pound chair against their door and cover themselves with a sheet or towel because staff entered the room without knocking, while the resident was disrobed at that time. Another resident stated that staff had to create a sign for their door because staff would otherwise walk in without announcing themselves. 2 of 10 residents did not confirm nor deny the allegation and stated they don't know if staff knock on their door before coming into their room or if staff have walked into their room without knocking. 4 of 10 residents denied the allegation and indicated staff knock on their door before coming into their room most of the time or always, staff have not walked into their room without knocking, and they feel they have privacy in their room. On 02/27/2026, between the hours of 2:25pm - 2:30pm, LPA conducted a records review & observed the following:The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes related to a staff member entering a residents room without knocking before walking into the residents room. Unsubstantiated: 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. Allegation: Staff unable to communicate with resident due to language barrier It was alleged that facility staff is unable to communicate with the resident due to a language barrier.  A staff worker has a hard time understanding the resident because the staff speaks their language a lot. When the resident complained to the staff worker, the staff worker told the resident that they did not understand the resident and that the resident needs to write theirs concerns on paper which staff would look into it. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and mentioned at times the facility has had difficulty understanding or communicating with specific residents. A1 disclosed if a resident speaks to staff and they don't understand them, staff call the receptionist to have another staff who can interpret and at the same time use the Google Translator app. A1 stated residents have complained that staff don't understand them, and when that happens, A1 sends a request for another staff to translate. A1 mentioned training has been provided on how to communicate with residents who speak different languages. On 02/19/2026 between the hours of 9:26am -11:43am, LPA conducted 5 staff interviews regarding the allegation. 5 of 5 staff denied and stated that they have receive training on how to communicate with residents who speak different languages. However, all staff indicated if a resident speaks to them and they don't understand, they get assistance from another caregiver who speaks the same language as the resident or inform the Administrator. Staff noted residents have not complained that they don't understand them. Staff disclosed some residents are difficult to understand due to dementia but not due to language barriers. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 3 of 10 residents confirmed the allegation and indicated they have had trouble getting staff to understand what they need or want. Of the 3 residents who confirmed the allegation, 1 resident stated staff have an foreign accents such as Spanish, West Indies, British, or Creole with staff answering questions with part English mixed with another language, and they don't understand staff most of the time. This same resident also mentioned nothing gets done if the staff doesn't understand. Since staff members doesn't understand, it results in yelling or displays of authority—yet the Administrator refuses to address these underlying communication problems .1 of 10 resident did not confirm nor deny the allegation and noted they have had trouble getting staff to understand what they need or want, but also indicated they make sure they are understood. 6 of 10 residents denied the allegation and indicated they have not had trouble getting staff to understand what they need or want. The resident also mentioned no staff member has told them they don't understand them and staff understand them when they ask for help and or have witness staff finding solutions. Report continues on LIC 9099-C On 02/27/2026, between the hours of 2:25pm - 2:30pm, the LPA conducted a records review and observed the following: The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes related to the alleged language barriers between the resident and staff. Unsubstantiated: 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. Exit interview conducted with Wendy Wheeler (Retirement Counselor) and a copy of this report was provided.