Complaint Investigation Report

Allegations: “Staff did not provide resident with assistance in a timely manner” and “Staff did not treat resident with respect”

It was reported that Resident #1 (R1) was left unassisted on the evening of 01/21/2026 which resulted in R1 spending the night in their wheelchair. It was also alleged that on 12/18/2025, overnight staff mocked R1 and did not provide them with assistance. Interview with R1 revealed that at approximately 6:25PM on 01/21/2026, they had dinner and asked who would be assisting them with preparing for bed. They were informed that Staff #1 (S1) would assist; however, S1 never arrived. At approximately 9:25PM, R1 called the facility phone and S1 told them they would be assisted shortly. Assistance did not occur, and when R1 called again, there was no answer. R1 remained in their wheelchair throughout the night and was afraid to fall asleep until Staff #2 (S2) found them the following morning. R1 stated they did not use their call button that night. R1 also reported that they enjoy living at the facility, that the Administrators address concerns promptly, and that staff generally treat them well. R1 denied experiencing disrespect or mocking from staff and expressed a preference for certain caregivers.

S1 reported that R1 typically returns from Dialysis between 6PM and 6:30PM, waits about an hour before requesting dinner due to post-treatment weakness, and then receives assistance with bedtime preparation around 8:30PM. On 01/21/2026, S1 stated that R1 refused assistance and requested a specific caregiver who was not scheduled. S1 reported offering assistance multiple times, but R1 allegedly became angry and yelled at S1 to leave. When S2 arrived for their shift, S1 informed them of R1’s refusals. S2 attempted to assist but was also unsuccessful. S2 reported checking on R1 every two (2) hours and leaving R1’s door slightly ajar to maintain visual monitoring due to R1’s agitation and yelling. S2 observed R1 to sleep and watch TV in their wheelchair throughout the night. S2 stated that R1 used their call button once and also called the facility phone between 4AM and 5AM requesting restroom assistance. Additional staff interviews indicated that R1 frequently refuses assistance and requests specific caregivers who may not be available, though staff attempt to accommodate these preferences. Staff denied witnessing or engaging in disrespectful behavior toward residents.