Complaint Investigation Report

On 7/9/25, LPA conducted a 10-day visit to the facility, made observations, obtained pertinent records and conducted interviews with staff. During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 reached out to another staff (S2) and told them in Spanish "ayudame con esta", which translates to "help me with this" not referring to resident's name. Once S2 came to the resident’s room, both caregivers initiated the transfer without communicating their intentions to the resident. Upon LPA’s inquiry about both staff not communicating with R2 their intention of transferring R2 from their wheelchair to their bed, their response was that R2 was non-verbal, but they stated that R2 could hear us perfectly. However, they never communicate with R2. Based on staff training records for both caregivers it indicates that staff have received personal rights training, including the dignity of residents and personal care with residents’ transfers within the last year. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Another allegation of facility staff did not follow physician care orders. The Reporting party stated that on 6/27/25, R1 was observed to be transferred using one-person assist by staff (S1), S1 lifted R1 by their upper extremity, which R1 has repeatedly identified as a source of pain. Despite doctor’s order to use a gait belt, S1 continue to use extremity during transfers, these instructions do not appear to have been followed. On 7/9/25, During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 selected resident (R2) who was in the common area in their wheelchair with other residents watching tv. S1 initiated pushing R2's wheelchair towards their bedroom without notifying R2 of the reasons why they were been transferred to their room, then S1 reached out to another staff (S2) to help with transfer. Once S2 came to R2’s room, both caregivers initiated the transfer without communicating their intentions to the resident, wheelchair was not positioned near nor parallel to the bed, both lifted the resident from their wheelchair and threw them to the bed by pushing their legs with their foot and not even holding their head to prevent them from possibly hitting the wall.