Complaint Investigation Report

On 07/23/2025 and 08/20/2025, LPA interviewed five (5) staff members (ED, S1-S4) and five (5) residents (R1-R5).

ED stated that on 07/06/2025, R1 reported that a caregiver (S5) had entered their room and caused harm. R1’s family expressed concern, and S5 was suspended pending investigation. Law enforcement was contacted and interviewed R1 the same day. No injuries were observed, and accounts of the incident were inconsistent. S5 resigned the following morning. The facility completed an internal investigation, which concluded that no abuse or injuries occurred. R1’s family was satisfied with the facility’s response and requested that S5 no longer provide care to R1.

S1 stated that R1 was observed to be anxious and shaken. Staff checked for injuries and none were found. S5 was suspended and later resigned. Hospice was notified and assessed R1, confirming that there were no injuries. R1 did not report the incident again, and R1’s family expressed that R1 was comfortable and that the staff were supportive.

S2 stated that R1 had fragile skin and bruised easily. S2 stated that S2 used extra precautions when providing assistance to R1 and asking another staff member for help. S2 reported providing activities of daily living to R1, regularly checking for bruises, and stated that no injuries were observed after R1 reported the incident. R1’s family visited frequently and did not raise concerns.

S3 stated that R1 preferred care from specific caregivers and bruised very easily, even with a light touch. S3 stated that hospice staff and caregivers regularly checked on R1 for bruises. R1 was handled carefully, and no injuries or physical abuse were observed.

S4 stated that on 07/06/2025, staff reported that R1 appeared upset and faint bruises were observed on R1’s arm. The concern was reported to management, documented, and shared with R1’s family. Law enforcement was contacted and R1 was interviewed. R1 expressed not wanting to leave the facility. No further complaints were made by R1, and no prior history of rough handling was found in the S5’s file. S5 later resigned for other employment.

R1 stated that R1 was satisfied with the care and services at the facility. R1 stated that a nighttime staff member had made them uncomfortable, expressing concerns about the staff member’s behavior, and was later terminated. Law enforcement was contacted in response to the concern. R1 expressed feeling comfortable with the current staff and reported no ongoing issues, and stated they were happy living at the facility.