complaint·February 6, 2025

The investigation revealed the following: Allegation: Staff left resident in soiled briefs for an extended period of time. It is alleged that a resident was left in soiled briefs for hours at a time with staff refusing to clean them when asked. Based on interviews conducted with S1-S3, 3 out of 3 staff interviewed denied the allegation. 3 out of 3 staff interviewed stated that residents are changed regularly and as needed. S3 stated that they change the resident’s adult briefs every 1-2 two hours and when needed. The department conducted an interview with R2 and attempted to interview R3-R4. The interview conducted with R2 revealed that staff are frequently checking on the residents. R2 stated that staff change the resident’s adult briefs frequently and when needed. R2 stated that although they don’t require as much assistance, staff is readily available if they ever do need staff to assist them with anything. R2 stated that they are satisfied with the services being provided to them at this facility. Based on observations, and interviews conducted, there is no sufficient evidence to prove the above 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 sleep at the facility while on shift. It is alleged that a resident had to call 911 several times to have police come out and wake up staff. Based on interviews conducted with S1-S3, 3 out of 3 staff interviewed denied ever sleeping while on shift. S2 stated that they are aware of a resident calling 911 several times one night, and when emergency services arrived, staff was awake, so emergency services just left. S2 stated that when the resident called 911 again, emergency services no longer came to the facility, instead they would just call and make sure things were okay. An interview conducted with R2 revealed that they have never witnessed staff sleeping while on shift. R2 stated that staff is always readily available to assist the residents with their needs. R2 stated that they are satisfied with the services being provided to them at this facility. Continued on LIC9099-C Based on observations, and interviews conducted, there is no sufficient evidence to prove the above 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 spoke inappropriately to resident in care. It is being alleged that a resident was told that it’s their fault and that they asked for it. Based on interviews conducted with S1-S3, 3 out of 3 staff interviewed denied ever speaking inappropriately to a resident. 3 out of 3 staff stated that they treat all resident with dignity and respect. An interview conducted with R2 revealed that staff have never spoken to them or the other residents inappropriately. R2 stated that staff is very nice and respectful towards them, and that they are very satisfied with the services being provided to them at this facility. Based on observations, and interviews conducted, there is no sufficient evidence to prove the above 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 provide meals to resident in a timely manner. It is alleged that a resident is not served breakfast until noon on most days. During a review of records, the department observed three weeks of the facility menu. The menu offers a variety of meals throughout the day, such as breakfast, lunch, dinner, including protein, starch, vegetables, and fruits. Based on interviews conducted with S1-S3, 3 out of 3 staff interviewed denied the allegation. 3 out of 3 staff stated that the residents receive 3 meals and snacks in between daily. 3 out of 3 staff interviewed stated that the meal times are 7AM-9AM for breakfast, 11:30AM-12:30PM for lunch, and 5PM for dinner. S3 stated that some residents sleep in, staff will go and ask them if they want to eat, but if the resident does not wish to wake up, staff will give them the option to have their breakfast at a later time. Continued on LIC9099-C An interview conducted with R2 revealed that staff is very attentive with the residents when it comes to their meals. R2 stated that they have 3 meals a day with snacks in between. R2 stated that the normal mealtimes are 8AM for breakfast, 12PM for lunch, and 5PM for dinner. Based on observations, and interviews conducted, there is no sufficient evidence to prove the above 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. During this investigation, the department did not find sufficient evidence to support the above-mentioned allegations, therefore no citations were issued. An exit interview was conducted with , and a copy of this report was provided.