Complaint Investigation Report

It was reported that “Staff did not provide proper first aid treatment to resident in care” as it was alleged that Resident #1 (R1) fell and was not provided first aid or care in a timely manner. Interviews conducted and records review revealed on 07/15/2025, R1 fell in the hallway near the bathroom. LPA’s interview with Staff #1 (S1) revealed they assisted R1 back to their room and offered R1 some ice, but R1 declined. S1 also stated they did not inform the Administrator or offer to call 911 after the fall. Additionally LPA’s interview with R1 revealed that although they did not feel like they were in any pain after the fall, staff only offered minimal assistance. The next day R1 decided to admit themselves into a local hospital. Based on information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred. Therefore, the allegations that “Staff did not provide proper first aid treatment to resident in care” has been deemed Substantiated at this time.

It was reported that "Staff yelled at residents in care" , as it was alleged that when resident’s requests assistance staff speak to them in inappropriate manner. Interviews conducted with five (5) residents in care revealed all (5) residents have observed S1 respond back to them in an inappropriate manner when requesting assistance with basic services such as food, toileting and transferring. LPA’s interview with S1 and Administrator revealed they denied ever speaking to residents in an inappropriate manner. Based on information gathered during the investigation the department has sufficient evidence to confirm these allegations occurred. Therefore, the allegations that “Staff yelled at residents in care” is Substantiated at this time.

It was reported that "Staff did not meet the residents' diapering care needs in a timely manner" as it was alleged that residents are left in soiled diapers due to staff not changing them in a timely manner. Interviews conducted with five (5) residents during the complaint investigation revealed that Resident #2 (R2) routinely requested diaper changes or for their Foley catheter bag to be emptied, but these requests were not addressed in a timely manner. Residents, including R2, reported that R2’s catheter bag was frequently more than half full. Additionally, R2 stated they do not have regular bowel movements; however, when they did, S1 often delayed responding to requests for assistance, sometimes for more than 10 minutes. Based on information gathered during the investigation, the department has sufficient evidence to confirm these allegations occurred. Therefore, the allegation that “Staff did not meet the residents' diapering care needs in a timely manner"” has been deemed Substantiated at this time