Complaint Investigation Report

RP alleged personal rights violation as they raised concerns regarding staff (S1) behavior that were described as “strict” and “rough”. Interview conducted with R1 stated they are always in pain, if you touch them it’s going to hurt regardless. R1 stated there was a staff member (S1) who no longer works at the facility, and had a language barrier issue as S1 did not speak English well. R1 stated if S1 was repositioning them and they expressed pain, S1 would say “I’m sorry”. R1 stated they do not feel that were abused.

RP alleged lack of supervision as another resident (R2) has dementia and will frequently enter or attempt to enter R1s room and has interfered with care. Interview with R1 stated that R2 has gone into their room and tried to take off their band-aid. R1 stated since R2 has dementia, R2 believes they are a caregiver at the facility. Interview with two out of two staff stated that R2 wanders and tends to wander more at night as R2 forgets where their room is. Staff stated when R2 wanders, they will redirect them back into their room.

RP alleged staff did not respond to resident’s call for assistance in a timely manner leaving R1 to be soiled for approximately 6 hours. Interview with R1 stated that sometimes it takes a while for staff to assist them but sometimes staff are quick and overall punctual. R1 stated they had been left soiled for approximately 5-6 hours one time. Interviews conducted with two other residents stated that staff respond to their calls when needing assistance quickly with no delay. Due to conflicting information and lack of documentation there is not sufficient evidence.

RP alleged that R1s call button from their room was not functioning during their visit. On 05/05/2026 LPA observed R1s call button to be working properly and alerted the staff when pressed.

RP alleged medications not administered as prescribed as there were multiple pills missing when R1 was first admitted into the facility and facility were unable to provide consistent medication administration records. RP also states when facility did provide documentation of medication being administered, multiple entries appeared to be written in similar handwriting and ink raising concern of accuracy. Review of R1s medication log do appear to be written in similar handwriting and ink. Although entry writing for medications given does appear to be written in similar handwriting and ink, there is not sufficient evidence to say medications were not administered as prescribed. LPA was unable to confirm missing pills as R1 had received a new order of prescribed medication and the old pill container had been discarded.

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.