complaint·October 27, 2025

(Continued from LIC9099) It was alleged that staff did not ensure the residents’ blood sugar was checked. More specifically, it was alleged that staff failed to check the R1's blood sugar. Staff interviews revealed that BG checks were offered by physician orders and refusals were documented. Resident interview revealed that R1 often refused checks due to discomfort or frustration with staff. Reporting Party (RP) interview confirmed the resident reported missed checks but also acknowledged R1 refusal. Records review showed consistent documentation of refusals by R1 and a temporary supply issue that was addressed. LPA observations confirmed that staff were aware of the care plan and continued to offer services. It was also alleged that staff retaliated against residents in care. More specifically, it was alleged that staff retaliated against the resident after R1 filed a complaint. Staff interviews denied any retaliatory behavior and stated that care was provided consistently. The resident interview revealed that R1 believed staff refused to check R1's sugar in retaliation, but R1 also admitted to avoiding the medication room. The RP interview confirmed R1's belief but acknowledged R1's behavioral challenges. Records review did not show any change in care following the complaint. The department's observations revealed no evidence of retaliation. It was also alleged that staff did not treat residents with dignity and respect. More specifically, staff made inappropriate comments about R1's physical condition. Staff interviews denied making disrespectful comments and described using calm redirection. R1's interview revealed that R1 felt disrespected by a comment from staff, but no witnesses could be identified. The RP interview confirmed the R1's report but could not provide verifiable witnesses. Records review did not reflect any inappropriate staff behavior. The department observations confirmed professional conduct by staff. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.