No Staff member stated that they had ever physically mishandled/handled roughly a resident. On 09/19/2023, Record review by the second LPA did not discover any evidence that a resident sustained a wound while in care. LPA received Physicians Orders/Audits from the primary care physician of certain residents dated from September of 2023 on a consistent basis (every day to every other day/occasionally every 3 days). LPA received copies of Medical Services provided to residents, regarding any wound a resident might have received while in care. LPA also received documentation of medical examinations for residents in September 2023. LPA received a copy of residents’ discharge summary from the hospital in August and September of 2023. LPA received detailed Doctor's Progress Notes from August 2023 and September 2023. LPA also received documentation of the facility 24 Hour Chart Check for the Resident for the months of August and September 2023. Interviews with facility staff members indicated that fragile or thin skin that tears easily is a concern with individuals at a certain age, but no resident had been moved by Facility Staff resulting in a wound opening on the resident that bled. From the record review of the medical documentation, 2^nd LPA found no evidence of physical marking on any residents due to handling by Staff. On 09/19/2023, LPA interviewed residents about the allegation and no resident interviewed by the LPA stated that they had been mistreated and/or treated roughly by the staff of the facility at any time while in care. There is no evidence of Staff mishandling residents in a physically rough manner. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms, this included changing residents, seating residents, etc. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be handled roughly after requesting or needing assistance. Continued on 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility staff verbally abused Resident(s). It is alleged that Staff members referred to the residents as the following: “They’re fucken crazy” “They have no idea what the fuck is going on” “such a bitch” “They shit so much and all they do is complain.” RP alleges that there were multiple incidents where Staff referred to the residents as: “So annoying” “I’m surprised they haven’t died yet” “They always do this shit and think we’re going to immediately run to their room when they need something” “They paged like 4 times now, they better be dying or some shit like that hahaha” “They can wait, the soiled sheets aren’t going anywhere.” “…you’ll see they’re all fucking irritating and you’ll start to hate them too” “They can’t hear shit… what’s the saying for ‘blind as a bat’ but for hearing? Hahaha.”

There is no evidence to corroborate the allegation that Facility Staff verbally abused resident(s). On 07/13/2021, the original LPA assigned to the complaint could find no evidence through interviews and record review to confirm that residents had been verbally abused by Staff. On 09/19/2023, the second LPA conducted interviews with Staff members and residents of the facility. No interview divulged any evidence that a resident had been verbally abused by a Staff member while in care at the facility. No resident stated they had been verbally abused while in care, or ever seen/heard another resident verbally abused while in care.

On 09/19/2023, a second LPA received documented records of the facility call button system usage for each resident from September 2023. The facility Call History documentation lists the call type: Emergency calls, Area, Room, Floor, Call Time, Wait Time, and name of the resident calling. From the documented facility call history, all resident call button usage was responded to by staff members. Wait time for each call varied depending on the type of call, as Emergency calls were responded to immediately. On 09/19/2023, LPA interviewed residents about the allegation and no resident interviewed by the LPA stated that Staff ever said anything about not wanting to assist the resident when they pressed their call button. There is no evidence of neglect by Staff during the hours recorded on the call button documentation, and there were no long wait times by residents. This evidence contradicts the alleged verbal abuse by Staff members about making residents wait for assistance. The facility call button history documentation shows that the wait times for residents in the facility did not increase in length in proportion to the number of calls a resident made on the call button sequentially. Continued on 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility did not accord Resident(s) with dignity. It is alleged that Staff members at the facility were pushing residents in wheelchairs when the resident clearly had their feet on the ground. It is also alleged that Staff members neglected specific residents because they were “annoying.” RP alleges to have heard the Staff members walking out behind the residents while laughing/mocking them.

On 07/13/2021, the original LPA conducted an initial complaint investigation visit to the facility above. LPA found no evidence that the facility did not accord residents with dignity. On 09/19/2023, a separate LPA conducted interview, observation, and record review at the facility above. LPA found no evidence that corroborated the allegation the facility did not accord the residents with dignity while in care.

There is documented evidence including interview, observation, and record review that the facility treats the residents with dignity and respect. During both complaint investigation visits by two (2) separate LPA’s, 07/13/2021 & 09/19/2023, all Staff members were observed to be treating each and every resident with dignity/respect. This included polite tone of speech & respectful manner of body language while speaking to residents, not speaking about a resident in a derogatory tone, privacy during treatment and personal care, the residents right to receive and make phone calls in private, send and receive mail unopened, and the right to associate privately with persons of resident’s choice.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C

On 07/13/2021, the first LPA assigned to this complaint conducted an initial complaint investigation visit to the facility above. LPA interviewed staff members and residents in the facility. Neither staff members nor residents confirmed the allegation. Staff interviewed stated they had not observed any resident being forced into a situation they did not want to do. LPA did not observe any evidence of the allegation while at the facility. On 09/19/2023, a separate LPA conducted record review of the records/documentation for bathing for residents and the Staff logs from the facility on 09/19/2023. LPA requested & received the Call Button Logs from the facility and there is no evidence of neglect or ignoring residents by Staff during the hours recorded on the call button documentation. Additionally, there were no long wait times by residents. The facility call button history documentation shows that the wait times for residents in the facility did not increase in length in proportion to the number of calls a resident made on the call button sequentially. The Call Button History Documentation shows that all residents had a wait time from less than a minute to approximately under half an hour. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be left for 3 hours or more after having pressed the call button for assistance. This is corroborated by the record review documentation of the facility call button system usage. There is no evidence to corroborate/confirm the allegation that the facility staff are not meeting the needs of the resident(s) in care. On 09/19/2023, the second LPA interviewed residents who stated that they had never failed to have specific needs met by the Staff such as changing, bathing, cleaning linens, eating, medication management assistance, etc. On 09/19/2023, LPA obtained copies of resident medication records and physician order reports for residents, maintained in each resident’s record/file. Upon observation & record review, there were no unmet needs identified by a physician that were not being appropriately addressed by the facility Staff. Contd. 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility failed to safeguard Resident(s) belongings. It is alleged by RP that there was stealing going on in the facility. RP stated that allegedly an electric temperature checker had been stolen from the facility, and that previous thefts of resident belongings by Staff members had occurred.

On 07/13/2021, the first LPA conducted an initial complaint investigation visit to the facility above. LPA conducted both Staff member & resident interviews, direct observations, and record review of pertinent information/documentation. LPA could find no evidence through interviews with Residents, Staff, Witnesses, LPA observation, and record review to confirm that facility failed to safeguard resident(s) belongings. On 09/19/2023, the 2^nd LPA assigned to the complaint investigation obtained and reviewed the facility Residence and Care Agreement regarding Property Rights, Conduct & Respect of Accommodations, and the Personal Property/Theft and Loss Policy. The facility shall not be responsible for the loss of any personal property (including, without limitation, money, valuables, and other personal effects) belonging to residents, guests, or invitees, due to theft, fire, or any other cause, except to the extent the loss or damage was caused by facility negligence or intentional misconduct, including that of the Staff members. The facility strongly recommends that each resident obtain, at their own expense, insurance for the replacement value of their personal property, at adequate coverage and liability limits. This provision will survive termination of this Agreement. Residents are encouraged to carry personal property insurance to cover any loss due to fire, theft, or other casualty. A general inventory of personal belongings will be conducted at time of move-in, but the facility is not responsible for any loss of money, jewelry, or other valuables. Residents are encouraged to leave valuables/money with family members or in a bank. No witnesses interviewed indicated seeing staff take any resident property from any resident room at any time. The facility does not maintain LIC621 Client/Resident Personal Property and Valuables documentation. The facility does not maintain LIC405 Record of Client’s/Resident’s Safeguarded Cash Resources documentation. Theft of resident belongings/money will be documented and upon request by the resident, theft and loss records will be made available to governmental and law enforcement agencies. In this instance, the resident did not request any action taken on the part of the facility according to the Residence and Care Agreement. Contd. 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of the report provided to the facility.