complaint·November 6, 2025

Per the administrator and staff, S1 denied not assisting R1 in changing the adult brief. S1 acknowledged R1’s call button and checked the diaper but it was not soiled. Staff told the resident that the adult brief was not soiled but eventually fulfilled the request. Other staff interviewed have not heard or witnessed any staff not assisting residents when needed. Staff stated they check on the residents at least every 2 hours to ensure their adult briefs are not soiled. LPAs obtained a copy of the “Alarm History” for R1 on 10/28/25 through 10/30/25. The log shows that R1 had requested assistance during the overnight hours and S1 responded to the calls. Ten (10) residents were interviewed during the visit. One out of the ten residents stated that S1 refused to change the resident because the resident did not need a diaper change or was not changed too long ago. The rest of the residents did not have any concerns regarding S1 and that staff assist them with their needs when needed. Based on the information gathered, there is insufficient information to corroborate this allegation. Allegation - Staff handled the resident in a rough manner. It is alleged that Staff #1 (S1) pulled the pendant off of Resident #1 (R1) and shoved the resident. Seven (7) of the Staff interviewed today stated they do not handle residents in a rough manner. Staff have not observed other staff shoving or pushing a resident or handling residents roughly. Nine (9) out of ten (10) residents do not feel that staff handle them in a rough manner. One of the residents stated that S1 was shoved as staff was grabbing the resident’s pendant and the string came apart. There were no witnesses to support this allegation, therefore, the allegation is unsubstantiated. Allegation - Staff speak to residents in an inappropriate manner. It is alleged that Staff #1 (S1) engaged in an altercation because the resident kept pressing the call pendant. Staff interviewed have not witnessed other staff arguing with a resident. Staff stated they received training in communication with residents. Staff do not yell or talk back to residents inappropriately. Eight (8) out of the ten (10) residents stated that staff are respectful and do not engage in any altercations. Two (2) of the residents stated that staff have yelled at them when they needed assistance. The witness to this allegation stated that S1 did not exchange any inappropriate words with R1. S1 explained to R1 that resident was not wet and did not need to be changed. Based on interviews, there is insufficient evidence to corroborate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with administrator M. Guardian. A copy of this report, along with the appeal rights, was provided.