Complaint Investigation Report

However, the caregiver did not come to R1’s room until about 10:00 PM. The LPA interviewed the Administrator and four (4) out of four (4) staff and they all denied the allegation. The Administrator and four (4) out of four (4) staff stated that they provide care to residents immediately but when staff is busy attending to other residents, it doesn’t take more than twenty to twenty-five minutes for them to respond. The Administrator and two (2) out of four (4) staff stated that when they visit R1’s room when R1’s asleep, they attempt to wake R1 but R1 does not wake up and is in deep sleep so they attempt to wake R1 at a later time. R1 also confirmed that when R1’s asleep, care staff try to wake R1 up but R1 does not wake up and R1 feels that the staff should still be able to provide assistance despite being asleep. (7) out of eight (8) residents interviewed claim that the staff provide proper care in a timely manner. Five (5) out of eight (8) residents stated that the staff helped right away whenever they called for assistance. Three (3) out of eight (8) residents stated that they are properly changed by the care staff without any complaints or delays. Two (2) out of eight (8) residents stated that the care staff carefully do not rush in cleaning their bed and room. One (1) out of eight (8) residents corroborated with the allegation stating that for the most part caregivers help to check on R1 but two caregivers do not help at all. However, the resident stated that the two caregivers come to help when the resident calls the office. Based on record review, LPA observed Medication Administration Record (July 2025) and Resident One Hour Check logs, both claimed that R1 was not at the facility on July 17, 2025. Based on record review, LPA also observed that on the Resident One Hour Check logs, R1 is frequently out of the facility when staff conducts their hourly checks. W1 interviewed also denies the allegation and W1 stated that whenever W1 visits R1 and requests staff assistance, care staff immediately visit to provide assistance and that there are no long delays. LPA conducted a tour of the facility. Based on observation, the LPA checked that the beds, linens and the rooms were in good condition and clean condition in Rm#111, Rm#112, Rm#115, Rm#211, Rm#221, Rm#225. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was held with the Administrator, Gill Agas, and a copy of this report was provided.