complaint·February 6, 2026

On 5/6/2025 and 5/14/2025 the Department conducted complaint investigation visits and interviewed 6 Staff (S1 to S6) and 9 Residents (R1 to R9). 6 Out of 6 Staff stated he/she has had training on transferring residents. On 5/6/2025 and 5/14/2025 the Department interviewed 9 Residents. 7 Out of 9 Residents state he/she does not require transfer assistance from staff. R1 and R2 state staff help him/her with transfer assistance. R2 states one staff member doesn’t ‘do his/her job very well.’ R2 did not provide additional information regarding this incident. Review of staff training records from January 2025 to July 2025 to include but not limited to resident rights, resident communication, approach, handling and de-escalation. Staff did not attend to residents in care in a timely manner On 5/9/2025 and 5/14/2025 the Department interviewed 6 Staff (S1 to S6). 6 Out of 6 Staff stated he/she attends to residents in care in a timely manner. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 4 Out of 9 Residents state staff attend to him/her in a timely manner. 5 Out of 9 Residents states he/she does not use pendants. On 5/9/2025 the Department tested R2’s pendant and staff responded in under 5 minutes. On 5/14/2025 the Department conducted an additional test of pendant response times. R9’s pendant was tested, and staff responded in 3 minutes. Staff did not ensure resident's room was clean and sanitary On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed R1’s toilet to need a cleaning, and R1's room had an odor. Page 2 of 4 On 5/9/2025 and 5/14/2025 the Department interviewed 6 Staff (S1 to S6). 6 Out of 6 Staff states resident rooms are cleaned at least once a week by housekeeping. S1 states if he/she observes a resident’s room to have trash on the floor, he/she will pick up the trash. S1 states if he/she observed a toilet in need of cleaning, he/she will inform housekeeping. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 9 Out of 9 residents state staff clean his/her room. On 5/14/2025, LPA Monter observed 4 random resident rooms as clean, sanitary, odor free, and in good repair. S taff are not following infection control protocol On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states he/she observed a staff member change a resident without using gloves and the staff did not wash his/her hands. On 5/9/2025 and 5/14/2025 the Department interviewed ED. ED states all staff have infection control protocol and wear gloves when caring for residents. ED states he provides this training directly to staff, and ensures staff follow protocol by conducting random checks on staff to ensure staff are wearing gloves and washing hands after caring for a resident. On 5/9/2025 and 5/14/2025 the Department interviewed 5 Staff (S1 to S5). 5 out of 5 staff state he/she has had infection control protocol training and wear gloves and wash his/her hands before and after caring for residents. S1 states he/she always carries gloves in his/her apron and pulled out gloves to show LPAs during the interview. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 4 Out of 9 Residents states staff wear gloves and staff wash hands when providing care to him/her. 5 Out of 9 staff state he/she does not know if staff wear gloves or wash hands. R3, R4, R5, R6, R7, and R8 state he/she doesn’t pay attention to whether staff are wearing gloves or washing hands. Page 3 of 4 Staff engaged in verbal argument in front of resident On 5/6/2025 the Department interviewed the Reporting Party (RP). RP states on 4/29/2025 he/she engaged in an argument with staff in front of R1. On 2/6/2026, the Department interviewed ED. ED states he is not aware of any staff arguing in front of residents at any time. On 5/9/2025 and 5/14/2025 the Department interviewed 5 Staff (S1 to S5). 5 out of 5 staff state he/she is not aware of any staff arguing in front of residents. On 5/9/2025 and 5/14/2025 the Department interviewed 9 Residents (R1 to R9). 9 Out of 9 residents state he/she is not aware of any staff arguing in front of residents. Review of staff training records from January 2025 to July 2025 to include but not limited to topics such as resident rights, resident communication, approach, handling and de-escalation. This agency has investigated the complaint alleging staff did not provide proper transfer assistance to resident in care, staff did not attend to residents in care in a timely manner, staff did not ensure resident's room was clean and sanitary, staff engaged verbal argument in front of resident. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED) Alex Baiasu and a copy of this report was provided. Page 4 of 4 END OF REPORT