complaint·April 3, 2025

Regarding the allegations, “Administrator speaks inappropriately to staff and residents and Staff force feed residents ” it is the reporting party’s concern that Staff #1 (S1) yells at the staff in front of the residents and yells at Resident #1 (R1), Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) when it comes to eating, and if the residents spit out their food, S1 will put it back in their mouth and S1 expect staff to force feed residents. To investigate the complaint the LPA conducted interviews with staff, witnesses, and residents, and on 02/13/25 observed residents and staff during lunch. All staff, witnesses, and resident family members revealed that S1 does not yell at the residents or at staff in front of the residents, S1 has a loud voice and can be firm but is not demeaning and have not observed S1 or any staff force feed the residents. Furthermore, staff stated that if they heard S1 yell at the residents they would report it. All staff, including S1, denied ever yelling at the residents and denied force feeding any of the residents. Additionally, staff revealed that they encourage residents to eat but do not force feed them. All the resident interviewed revealed that they have not been yelled at or spoken inappropriately to. In addition, majority of the resident’s interviews revealed that they have not heard S1 yell or force feed the other residents. Lastly, on 02/13/25, the LPA did not observe S1 or any staff yell or force feed any of the residents during lunch, or at any point during the initial and subsequent visits. The LPA observed staff assisting and encouraging residents to eat and once residents did not want any more, staff did not force feed residents. Based on the information gathered, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred; therefore, the above allegations are deemed UNSUBSTANTIATED at this time. Regarding the allegation, “Staff are not meeting residents’ diapering needs” it is the reporting party’s concern that they received information that the residents are not being diapered during the night. Interviews with family members of three residents that required incontinence care revealed no concerns regarding resident’s toileting needs. Family members expressed satisfaction with the care provided at the facility, describing staff as wonderful, attentive and accommodating. Staff interviewed revealed that they do not work the overnight shift but that when they come in the morning, they have not witnessed residents with soaked diapers. One witness revealed that residents can be soaked in the morning, however it is not frequently, and another witness revealed that they have observed a resident with wet pants, however it did not seem like it was old, resident’s skin was okay and no rash. During today’s visit the LPA observed staff doing their rounds and taking residents to get incontinence care. Report will continue on LIC9099-C, 3rd page. Lastly, file review revealed that every time a resident gets changed it is documented on a daily output log. The LPA observed documentation of the log being filled out during the night. The administrator revealed that they work the night shift and check on the residents and change them every two to three hours. Based on the information gathered, although the allegations may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation is deemed UNSUBSTANTIATED at this time Exit interview and report review was conducted with Administrator. A copy of the report was given,