Complaint Investigation Report

The investigation revealed the following. Regarding Allegation: Staff does not treat resident with respect - It is alleged that S10 shouted and did not treat R1 with dignity on or around 8/17/2024. Five (5) out nine (9) staff verbally interviewed corroborate this allegation. LPA Ramirez observed three (3) written statements by three facility staff that corroborate this allegation. S10 was not available for interview during visit and LPA Ramirez attempted to contact S10. According to staff, S10 resigned effective 8/22/2024. One (1) out of one (1) resident interviewed deny this allegation. Residents that reside in the Evergreen unit suffer from cognitive impairments; LPA Ramirez was unable to conduct additional resident interviews. During staff interviews and records reviewed, it was revealed that on multiple occasions S10 was observed by other staff to shout and refuse to assist residents with activities of daily living. Written statements by facility staff revealed on 7/15/2024, S11 documented that S10 left R3 soiled in feces for more than 4 hours. LPA Ramirez observed a written statement by S5 that documented on or around 5/15/24 or 5/16/24, S10 raised their voice at residents’ family while searching for a resident’s shirt. Interviews with staff revealed S10 was heard redirecting residents by shouting and refusing to assist other staff reposition residents upon request. Based on interviews and and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated .

One (1) deficiency is being cited during this investigation. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.