Complaint Investigation Report

On 07/07/2025, LPA conducted a subsequent visit at 9:30AM. Beginning at 9:41AM, LPA reviewed and obtained additional documents and interviewed two (2) staff between 11:08AM and 11:40AM. At 11:23AM, the LPA and Front Office Receptionist conducted a tour of the facility.

During today’s visit, the LPA and the ED toured the facility at 10:32AM to ensure there are no health and safety hazards. No immediate concerns were observed. The following was determined:

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

It was reported that Resident #1 (R1) did not receive showers or assistance with care needs when requested. R1 revealed that Staff refused to help with their wheelchair and claimed Witness #1 (W1) stated R1 can manage themselves independently. R1 also stated that Staff claimed R1 was not on the shower list when they requested a shower. W1 stated that R1 can complete tasks such as walking and wheeling themselves in their wheelchair, but did not instruct Staff not to assist R1. Interviews with seven (7) Staff confirmed that R1 frequently requested assistance but often changed their mind, and Staff did not report denying assistance. R1 is offered showers twice a week but commonly refuses them. Staff #1 (S1) explained that R1 requested to move their morning showers to the afternoon. After the adjustment was made, R1 then changed their preference back to the mornings, and Staff scheduled accordingly. S1 noted that Staff attempted to accommodate to R1’s needs, although R1 often contradicts themselves. Interviews with nine (9) residents indicated that Staff generally assist residents with their needs but can be slow to respond and fall behind on showers, depending on their current tasks. Resident #2 (R2) stated they had to shower without help once due to the Staff being occupied. Resident #3 (R3) reported missing scheduled showers because of staffing issues. According to Staff #2 (S2), all showers are required to be logged before the end of each shift, indicating whether the residents received or refused the offered shower. Refusals must also be reported internally. Agency Staff are also trained in this procedure, however S2 noted they fail to complete the logs.