Complaint Investigation Report

Allegation: Staff did not adequately assist resident with care needs in a timely manner.

It was alleged that Resident #1 (R1), who uses a walker and requires assistance with ambulation and restroom use, experienced delays in staff response times when requesting assistance. It was further alleged that due to delayed responses, R1 attempted to ambulate independently and nearly fainted in the restroom on an unknown date. To investigate this allegation, LPA conducted interviews with the Administrator and Staff #1 (S1). Both denied the allegation. The Administrator stated that R1 always received assistance shortly after requesting help and that staffing levels were sufficient to meet resident needs. Staff reported that residents are monitored and assisted as needed. LPA interviewed R1 on 02/04/2025, who reported concerns regarding delays in staff responding to requests for assistance and described an incident on an unknown date in which R1 nearly fainted while using the restroom. During the visit on 02/04/2025, LPA observed staff present and providing care and supervision to all residents including R1. Based on LPA’s observation during the initial and subsequent visits, staff were available to assist residents and respond to care needs. Based on interviews conducted and LPA’s observation during the visit, there was insufficient evidence to support the claim that staff did not adequately assist R1 with care needs in a timely manner. Therefore, the allegation is Unsubstantiated . The finding is based on information gathered during the investigation regarding conditions and practices during the time R1 resided at the facility. At the time the investigation concluded, R1 was no longer residing at the facility.

Allegation: Staff did not respect resident’s choices regarding their care needs.

It was alleged that staff did not respect R1’s expressed care preferences. Specifically, it was alleged that an unknown individual provided a shower to R1 without proper identification and performed an unsolicited massage despite R1 verbally objecting. To investigate this allegation, LPA interviewed the Administrator and S1, both of whom denied the allegation. The Administrator stated that showers are provided by a designated shower aide and that the facility does not provide massages to residents. Although the Administrator was initially unable to identify the individual who provided the shower at the time of questioning, documentation obtained during the course of the investigation clarified that R1 was enrolled in hospice services with Glendale Hospice Inc beginning 01/24/2025. Records reviewed indicate that R1 received two hospice visits dated 01/28/2025 and 01/31/2025. During both visits, hospice staff provided shower assistance using a shower chair and applied lotion to R1’s skin as part of routine personal care. Documentation further reflects that R1 was discharged from hospice services on 01/31/2025 at the request of R1’s Power of Attorney (POA), who revoked hospice benefits and service Continue on LIC 9099C