Complaint Investigation Report

On January 28, 2026, the Department requested and obtain the following documents via email: Resident rights training (dated 3/27/25), Incontinent care training (dated 3/6/25), Service plan, physician’s report, and pre-placement appraisals for Residents (R1-R5), Incident/death report for R3 (dated 3/25/25). On January 29, 2026, The Department conducted interviews with Assistant Administrator (A2), and 4 staff (S1-S4)

The investigation revealed the following:

Allegation: Facility Staff neglected the needs of residents in care.

The detail of the complaint alleges R1-R5 has been neglected by staff: Dinner was allegedly withheld from R2 and served 2 hours later, decline in R3’s health and sudden death allegedly was a result of neglect. R4 reportedly was left soiled for an extended period without being changed. R5 allegedly was denied cake repeatedly when R5 asked for it.

On April 2, 2025, the Department interviewed 3 residents regarding the allegation, and on April 25, 2025, 5 additional residents were interviewed. 8 out of 8 residents denied the allegation, stating that staff provide appropriate care and they have not experienced neglect. Each resident confirmed that dinner is always served on time, snacks are never withheld, and 8 out of 8 residents indicated that they have never been left soiled for an extended period.

On January 29, 2026, at 11:15am the Department interviewed Assistant Administrator (A2) who denied the allegation stating that no resident is ever denied food, residents are changed regularly and/or as needed. Additionally, A2 states that all staff have had Resident Rights training, and training on caring for incontinent residents. Lastly, A2 states that R3 was on hospice care at the time of her passing so A2 denies that there was neglect related to R3’s death.