Complaint Investigation Report

Regarding the allegation, “Staff did not ensure resident was assisted in a timely manner,” it is being alleged that Resident #2 (R2) was not ready for scheduled pick-up on 06/24/25. Record review of R2’s Physicians’ Report revealed that R2 is able to dress and groom self, able to communicate, and leave the facility unassisted. Interview with Wellness Director indicated that R2 is independent. Wellness Director indicated that when a resident is independent, appointments are not tracked unless the facility is providing transportation. Four out four staff interviews (S2 – S5) indicated that staff communicate with each other to have the resident prepared for timely pick-ups. One out two resident interviews (R3 – R4) indicated that staff have them prepared for pick-ups. Three out of three resident interviews (R1- R2, R7) indicated that they are independent. Witness #1 indicated that resident is assisted in a timely manner.

Regarding the allegation, “Staff did not ensure resident was assisted in a timely manner,” based on interviews and record review, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation, “Staff do not provide activities for residents,” it being alleged that on several occasions, wheelchair-bound residents were placed in front of the television for an extended period of time instead of being engaged in other activities. Record review of January through March 2025 activity schedule revealed that activities were scheduled from 9:00 AM – 6:30 PM from Sunday through Tuesday, Thursday, and Saturday. Activities were scheduled from 9:00 AM – 8:00 PM on Wednesdays and Fridays. Record review of April - June 2025 activity schedule revealed that activities were scheduled from 9:00 AM – 6:30 PM from Sunday through Tuesday and Thursday through Saturday. Activities are scheduled from 9:00 AM – 6:00 PM on Wednesdays. Five out five staff interviews (S2 – S6) indicated that residents in wheelchairs are provided with activities. Interview with the Activities Director indicated that all residents in wheelchairs or diagnosed with dementia are encouraged to participate in events and outings. Seven out seven resident interviews (R1 – R7) indicated that staff provides residents with activities. Witness #1 indicated that the facility provides activities. LPA observed residents engaged in activities located in the common areas.

Regarding the allegation, “Staff do not provide activities for residents,” based on interviews, record review, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continue to LIC9099-C.