The details of the complaint alleged that the facility’s staff did not assist resident (R1) in care. It was reported that resident (R1) asked to be taken to the smoking area because they had a previous fall and staff refused and allegedly stated that R1 should be healed by now and can go by themselves. On 5/6/2026, from 9:30am-2:00pm, the department interviewed administrator (A1), staff (S1-S4) and residents (R1-R7) regarding the allegation. The administrator (A1) and staff (S1-S3) denied the allegation and stated that they have never refused to assist a resident in care. Staff (S4) stated that the resident was upset that they were asked to leave the non-designated smoking area and to go the smoking area because they were smoking at the front entrance. S4 stated that the resident flicked their cigarette into the bushes and stated, “then you are going to take me”.

S4 explained the reason that they did not wheel the resident to the smoking area is because the resident is not on escorts, which is a service that some residents use who are not able to get around without assistance. S4 further stated that the resident did not need assistance and was capable of going to the smoking area without assistance. S4 stated that eventually R1 wheeled themselves to the smoking area by themselves without further incident in their electric wheelchair.

The department interviewed residents (R1-R7) about the allegation and 6 of 7 residents that were interviewed stated that staff has never refused to assist them when they have asked. While R1 stated that they were recently released from the hospital and had a sprained shoulder and was still in pain and needed help, but staff did refuse to assist them.

The department reviewed Pre-Placement Appraisal (Dated: 01/04/2026), Physician Report (Dated: 11/18/2025, 05/07/2026), RCFE Service Plan (Dated: 06/10/2026), and the After Visit Summary from Providence Emergency Center (Dated:04/05/2026) and observed that R1 has used an electric wheelchair independently since they arrived at the facility and had no motor impairment or paralysis. The department also observed that the resident had a fall that resulted in a shoulder sprain and was taken to the hospital on 04/05/26. The department did not observe any documentation from that visit that specified the resident needed additional assistance or suffered any motor impairment or paralysis after their last hospital visit.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not assist a resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were found and no citations were issued for this complaint investigation.

An exit interview was conducted with Maria Galvan, Executive Director, and a hard copy of this Complaint Investigation Report was provided.