Complaint Investigation Report

Regarding the allegation that Staff do not clean resident properly after using the restroom, it was reported that resident was accompanied to the bathroom but didn’t receive assistance. Resident (R1) had to clean themselves. Per review of physician’s report dated February 26, 2026, R1 is legally blind. Per review of preplacement appraisal information, R1 uses wheelchair, requires assistance with bathing and personal hygiene, but does not require assistance with toileting. R1 reported that staff does not assist with changing and they had to change themselves. Two out of five residents interviewed stated they are not cleaned properly after the bathroom. Three out of five residents stated they don’t need assistance with cleaning. Two out of nine staff interviewed stated that R1 verbalized he did not require assistance with cleanup after toileting. Four out of nine staff stated they do assist R1 with cleaning. Three out of nine staff provided irrelevant answers. There is no evidence supporting the allegation.

Regarding the allegation that Staff do not treat resident with dignity and respect, it was reported that resident was asked to say “please” before being provided food. R1 reported they been insulted in Spanish. Per admission agreement dated February 25, 2026, residents of residential care facilities for the elderly shall be accorded dignity in their personal relationships with staff, residents, and other persons. Two out of five residents interviewed confirmed the allegation that they are not treated with dignity and respect. Two out of five residents denied the allegation. One out of five residents did not provide an adequate answer. Eight out of nine staff denied the allegation. One out of nine staff confirmed the allegation but could not provide further information. There is no evidence supporting the allegation.

Regarding the allegation that Staff did not ensure resident was fed before a medical appointment, it was reported that resident was not provided with a snack prior to their dialysis appointment. It was reported that R1 arrived at his appointment “hungry and dirty”. Per review of R1’s admission agreement, they are provided with three nutritious meals daily and between meals nourishment or snack. The facility does not document meals received. One out of five residents interviewed stated they receive snacks before and after an appointment. Four out of five residents did not have relevant information regarding the allegation. Two out of nine staff reported at times, they are not advised to feed them depending on the appointment. Seven out of nine staff reported residents are always provided with a snack prior to appointments. There is no evidence supporting the allegation.

Regarding the allegation that Staff do not allow resident to eat an alternative meal, it was reported that resident was not brought a different meal despite asking for one. Continued on LIC9099-C.