Complaint·April 30, 2025

An interview with the Executive Director (ED) revealed the ED had worked at the facility since 2021, and R1 had not reported any concerns regarding staff throwing coffee, or other items at R1. The ED recalled and incident where R1 and a separate resident were involved in a verbal argument. R1 refused to allow the other resident to enter the dining area, therefore, the other resident pushed through with a walker. The walker made contact with R1’s wheelchair, not R1’s head. R1 initially declined having any injuries, but later demanded R1 be transported to the hospital. R1 was transported, was evaluated, and returned with no injuries, nor orders. The ED had not received any reports of staff mistreating any of the residents. Interviews with external and internal sources, including staff and residents, did not recall ever witnessing staff, or residents, assaulting residents. Staff intervened and redirected residents when verbal arguments were observed. These interviews also revealed R1 had outbursts and displayed behaviors that were considered to rude to other residents. R1 could become verbally aggressive toward other residents. It was alleged staff did not treat residents with dignity. On March 20th, 2025, it was reported the facility staff treated residents poorly. Interviews with internal and eternal sources revealed staff treated residents with dignity. These sources had not witnessed any of the facility staff mistreat the any of the residents. Staff interactions with residents were described as good, nice, and having no concerns. It was alleged the licensee did not assist a resident with incontinence care. On March 20th, 2025, it was reported to the Department R1 went without incontinence briefs for one day while at the facility. Interviews with several residents did not reveal any concerns regarding lack of incontinence supplies. Interviews with staff revealed the facility had extra incontinence supplies stored at the facility, in case a resident needed them. The LPA toured the facility and observed the stored supplies, including incontinence briefs, and mattress pads. The LPA confirmed the medication technician on shift had a key to access these supplies. The LPA also observed residents’ personal incontinence supplies and residents reported having enough supplies. Interviewed staff did not recall R1 ever reporting not having incontinence briefs. The LPA attempted to interview R1, but R1 no longer resided at the facility. Based on the evidence obtained, the allegations were unsubstantiated. An exit interview was conducted with Lopez, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.