complaint·December 9, 2025

simple, clear language, avoid arguing; redirect gently. Maintain familiar routines and offer choices.  The staff were not displaying good  communication techniques, behavior management, and emergency response.  They were not objective. The staff did not records triggers, interventions and outcomes.  The staff did not utilize the basic standardized behavior tracking tools to assist R1 with adjusting to a new environment. On April 20, 2023, an allegation was received stating that facility staff did not follow required reporting procedures. Interviews conducted with staff indicated that they were familiar with reporting protocols and stated that incident reports were completed when residents exhibit unusual behaviors. However, documentation did not support these claims. A review of facility records revealed no incident reports, internal documentation, or other evidence indicating reports were completed for R1 during periods of unusual behavior. Additionally, Outside Source 4 (OS4) confirmed they were not notified of any incidents involving R1. This lack of documentation and communication was inconsistent with the facility’s obligation which requires licensees to report unusual incidents and maintain accurate records. The absence of incident reports and not notifying OS4 suggest noncompliance with reporting requirements. On April 20, 2023, an allegation was made that the facility staff did not treat the residents with dignity. Interviews were conducted with two (2) residents. The residents that were interviewed stated that staff treat them with dignity and respond to their needs in a timely and courteous manner. Outside source 3 (OS3) reported concerns regarding staff conduct and described staff as not compassionate nor professional. Outside Source 3 (OS3) stated that the facility staff were very unprofessional. The facility staff texted or called OS4 with multiple complaints that R1 was unruly and difficult to work with. Outside source 5 (OS5) reported witnessing undignified treatment towards R1 when transferring R1 to an alternative placement. OS5 was interviewed and they verified that the facility staff did not treat R1 with respect. The staff did not show dignity in packing R1's belongings when being transferred to another facility and cheering when the resident left the facility. A review of staff training records confirmed that all staff received training on resident rights regarding being treated with dignity. During the visit, staff were observed interacting with residents in a dignified and professional manner. Staff addressed residents by name, and offered assistance in a courteous way. The residents that the staff were assisting did not have dementia related behaviors. On April 20, 2023, an allegation was made that the facility staff did not treat the residents with respect. Interviews were conducted with two (2) residents. The residents that were interviewed stated that staff treat them with respect and respond to their needs in a timely and courteous manner. Interviews with two (2) staff members revealed that staff were aware of and trained on resident rights, including the importance of treating residents with respect. Staff were able to articulate examples of how they uphold these standards in their daily interactions. OS3 reported concerns regarding staff conduct and described staff as disrespectful. OS4 stated that the staff at the facility did not treat R1 with respect. OS5 was interviewed and they verified that the facility staff did not treat R1 with respect. They did not show respect in packing R1's belongings when being transferred to another facility and cheering when the resident left the facility A review of staff training records confirmed that all staff received training on resident rights.  During the visit, staff were observed interacting with residents in a respectful and professional manner. Staff addressed residents by name, offered assistance in a courteous way. The residents that the staff were assisting did not have dementia related behaviors. The department has investigated the above-mentioned allegations. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegations are substantiated. An exit interview was conducted, and a copy of this report and the licensee rights (LIC 9058 03/22) were provided to Gabriela Nafarrate Caregiver. Her signature on this form confirms receipt of these rights.