Inspection Reports for
Pasadena Villa Senior Living

The complaint alleged that a resident (R1) was kept in a wet diaper for prolonged periods and staff did not respond promptly to call buttons. Interviews with staff and residents, review of records, and observations did not provide enough evidence to substantiate the allegation. The complaint was determined to be unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation. Staff and most residents stated that incontinence needs were met with occasional delays, and observations confirmed adequate supplies and care practices.

The complaint investigation was unsubstantiated. Allegations included poor facility repair and lack of towels in bathrooms. Interviews with staff, residents, and administrators, along with observations, did not provide enough evidence to confirm the allegations.

The investigation found insufficient evidence to substantiate the allegations that the facility was not in good repair or that staff failed to provide towels to residents. Observations and interviews indicated minimal ceiling damage with no active leaks and that cloth towels were provided due to plumbing issues with paper towels.

The complaint involved allegations of staff substance use during work, staff providing residents with alcohol and drugs, and failure to safeguard resident belongings. The allegations were unsubstantiated due to lack of sufficient evidence despite interviews and file reviews.

The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff, review of records, and observations did not provide enough proof to confirm the reported violations.

The complaint alleged inadequate supervision leading to non-consensual sexual behavior by Resident #2 towards Resident #1. The allegation was unsubstantiated due to lack of corroborating evidence despite interviews, surveillance review, and police report.

The investigation found insufficient evidence to substantiate the allegation that Resident #2 inappropriately touched Resident #1's breasts or groin. Despite prior incidents of unwanted contact reported to management, surveillance and witness interviews did not confirm the alleged event, resulting in an unsubstantiated finding.

The complaint involved allegations that a resident was not accorded dignity, did not have access to a call pendant, was not provided a comfortable environment, and was denied privacy. After investigation, including interviews with residents, staff, and review of documentation, the allegations were found unsubstantiated due to lack of supportive evidence.

The investigation found insufficient evidence to substantiate any of the allegations after interviews with residents, staff, and review of records. The allegations were determined to be unsubstantiated.

The complaint alleged that staff were not properly intervening between residents' altercations, including verbal and sexual harassment by residents R2, R3, and R4 toward R1. The investigation included interviews with residents, staff, and the administrator, review of resident files, incident reports, and staff training documentation. Despite some corroboration from residents, staff and administration denied witnessing the harassment. Written warnings and increased supervision were documented. The complaint was determined to be unsubstantiated due to lack of sufficient evidence.

The investigation found allegations of verbal and sexual harassment among residents R1, R2, R3, and R4, with some residents corroborating the claims but not reporting them to staff. Staff and administration denied witnessing the alleged behaviors. Written warnings were issued to residents R3 and R4, and additional supervision measures were implemented. The allegations were ultimately unsubstantiated due to insufficient evidence.

The complaint alleged that a resident with dementia sustained an unexplained injury from an unwitnessed fall on August 11, 2025, due to staff neglect. The investigation included interviews with staff and residents, review of injury reports, and hospital records. The allegation was unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to corroborate the allegation. Staff provided care after the resident's fall, and residents interviewed denied the allegation or were unaware of the incident. The allegation was determined to be unsubstantiated.

The complaint alleged that staff do not ensure residents' medical needs are met. The investigation included interviews with staff, residents, and a wound care specialist. Resident R1 refused some care but staff were found to be providing appropriate medical attention. The complaint was unsubstantiated.

The investigation found that the wound care specialist visits the facility twice weekly and Resident R1 is being treated for wounds. Resident R1 refuses some medical care but staff provide assistance as needed. The allegations were unsubstantiated due to lack of evidence.

The complaint alleged that facility staff did not assist a resident with obtaining medical care, did not dispense medications as prescribed, and did not provide meals or drinking water. After investigation, including interviews and record reviews, the allegations were found to be unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegations. Interviews with residents, staff, and administrators, as well as record reviews, indicated that medical care and medications were provided as prescribed, and meals and drinking water were available to residents.

The complaint involved two allegations: failure to provide a resident monthly allowance and rough handling of a resident by staff. Interviews with staff, residents, and review of records did not provide enough evidence to substantiate either allegation. The report concluded the allegations were unsubstantiated.

The investigation found insufficient evidence to substantiate the allegations. Staff and most residents denied the claims, and documentation did not support the allegations. Therefore, the allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included lack of place for residents' belongings and non-working water. Resident and staff interviews, physical inspections, and document reviews did not support the allegations.

The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff, physical inspections, and document reviews indicated that dressers were in good condition and water repairs were temporary and completed. The allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included improper facility maintenance and presence of bad odors. Interviews with residents, staff, and observations did not provide enough evidence to substantiate the claims.

The investigation found insufficient evidence to substantiate the allegations. One resident corroborated the clogged toilet issue, but most residents and staff denied it. The clogged toilet was fixed on 07/01/2025. One resident corroborated an odor issue related to a leaking toilet base, but the bathroom was being cleaned daily and repairs were scheduled. No bad odors were detected during the visit.

The complaint investigation addressed allegations including neglect resulting in hospitalization for sepsis, failure to seek timely medical attention, failure to respond to resident calls for help, failure to meet dietary needs, and failure to notify residents' responsible parties. All allegations were found to be unsubstantiated due to lack of sufficient evidence.

The investigation found no preponderance of evidence to substantiate the allegations of neglect, failure to seek timely medical attention, failure to respond to calls for help, failure to meet dietary needs, or failure to notify responsible parties. Staff and residents largely denied the allegations, and records supported appropriate care and communication.

The complaint alleged that Resident #1 was being sexually harassed by Resident #2 through inappropriate touching and comments. The investigation included interviews with residents and staff, review of records, and a police wellness check. The allegation was unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegation. Multiple staff and residents denied the allegation, and records indicated no inappropriate behavior by the accused resident. The allegation was deemed unsubstantiated.

The complaint alleged that staff failed to assist residents with medical care and access to personal belongings. After investigation including staff and resident interviews and review of documentation, the allegations were found unsubstantiated due to lack of preponderance of evidence.

The investigation found that staff assisted residents with medical appointments and transportation, and retrieved residents' personal belongings upon request. Interviews and documentation did not corroborate the allegations, resulting in an unsubstantiated finding.

The complaint alleged that due to lack of supervision, Resident 1 physically assaulted Resident 2 causing injury and hospitalization. The investigation was unsubstantiated as evidence did not prove the alleged violation occurred.

The investigation found insufficient evidence to substantiate the allegation of neglect related to the physical assault between residents. Interviews, video footage, and documentation showed caregivers responded promptly and the police investigation was closed without charges.

The complaint investigation was unsubstantiated. Allegations included improper room cleaning and failure to safeguard residents' personal property. Interviews and inspections did not support these claims.

The investigation found no preponderance of evidence to prove the alleged violations occurred. Resident rooms were observed to be clean with no human waste or water leakage, and residents and staff reported regular cleaning. No complaints or evidence of stolen personal property were substantiated.

The complaint investigation was unsubstantiated. Allegations included staff pushing a resident out of their wheelchair, locking a resident in their room, and not safeguarding personal belongings. Interviews with staff and residents denied all allegations, and physical inspection of the facility supported these denials.

The investigation found insufficient evidence to substantiate allegations that staff pushed a resident out of their wheelchair, locked a resident in their room, or failed to safeguard a resident's personal belongings. Interviews with staff and residents, as well as document reviews, did not corroborate the complaints.

The allegation was that staff did not prevent residents from engaging in a physical altercation. After investigation, including interviews and review of documentation, there was insufficient evidence to substantiate the allegation. The complaint was unsubstantiated.

The investigation found that staff intervened immediately to separate the residents involved in the altercation and provided first aid. Interviews with staff and residents did not corroborate the allegation, and the complaint was determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not frequently changing residents, not meeting hygiene needs, and not providing cold water. Interviews with staff and residents, record reviews, and observations did not provide sufficient evidence to confirm the allegations.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents reported regular care and hygiene assistance, and cold water was available despite plumbing issues affecting hot water. The allegations were deemed unsubstantiated.

Allegation: Resident sustained an injury while in care. The resident presented to the hospital with a wound reportedly containing maggots. The facility denied the allegation and provided evidence of ongoing wound care and medical services. The resident's behavior included frequent refusal of care and absences from the facility. The investigation concluded the allegation was unsubstantiated due to lack of evidence.

The investigation found no preponderance of evidence to support the allegation of maggots in the resident's wound. The resident received wound care services and medical treatment, but frequently refused care and left the facility without notice. The allegation was determined to be unsubstantiated.

The complaint alleged that staff allowed a resident to be left in soiled clothing on 03/28/2024 and that residents were not adequately fed. The investigation included interviews with staff and residents, review of records, and observations. The allegations were found to be unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegations that staff left a resident in soiled clothing for an extended period and that residents were not adequately fed. Interviews with staff and residents, record reviews, and observations did not corroborate the complaints.

The complaint investigation was unsubstantiated. Allegations included staff disrespecting residents and stealing personal belongings. Interviews with staff and residents, as well as file reviews, did not corroborate these claims.

The investigation found no sufficient evidence to substantiate the allegations. Staff and residents consistently reported respectful treatment and no issues with missing belongings. The allegations were determined to be unsubstantiated.

The complaint alleged that staff did not prevent resident R2 from hitting resident R1 with a stick. Interviews and reports showed no visible injuries or pain to R1, and staff removed R2 promptly. The allegation was unsubstantiated.

The investigation found no concrete evidence that the alleged incident occurred. Staff intervened quickly and no visible injuries were observed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved two allegations: staff were unaware of a resident's whereabouts and staff failed to follow reporting requirements. The investigation included interviews with staff and residents and review of relevant documents. The allegations were unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied the claims, and the facility's procedures and resident rights were confirmed. The allegations were determined to be unsubstantiated.

The complaint alleged that Staff #1 grabbed and dug their nails into Resident #1's wrists. Surveillance footage showed Staff #1 attempting to take a plate of food from Resident #1, who resisted. Interviews with staff and residents found no evidence of rough handling. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation included review of surveillance footage, interviews with staff and residents, and examination of incident reports. The evidence did not support the allegation, and the complaint was determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included unclean showers, lack of laundry and housekeeping services, no hot water for showers, and menus not available for residents. Interviews with staff and residents, observations, and document reviews did not support these allegations.

The investigation found that staff and residents generally denied the allegations. Hot water was available though it took time to heat in some showers. Laundry and housekeeping services were provided according to schedules, with some refusals documented. Menus were posted and available for resident review. Overall, there was insufficient evidence to substantiate the allegations.

The complaint investigation was unsubstantiated. Allegations included unclean showers, lack of laundry and housekeeping services, no hot water for showers, and menus not available for resident review. Interviews and observations did not support these allegations.

The investigation found no substantiated violations. Staff and residents generally confirmed that showers were clean, laundry and housekeeping services were provided, hot water was available within regulatory standards, and menus were posted for resident review.

The complaint alleged that facility staff did not prevent an altercation between residents R1 and R2. The allegation was unsubstantiated based on interviews, incident reports, and observations.

The investigation found insufficient evidence to substantiate the allegation. Interviews with residents and staff indicated that staff attempted to de-escalate the situation and separated the involved residents. Authorities were called, no injuries were reported, and the residents have since been separated.

The complaint alleged staff failed to provide adequate supervision leading to a resident-on-resident altercation. The investigation included interviews with staff and residents, review of incident reports, and medical records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found that staff conducted resident room checks and intervened during altercations. Although an altercation between residents R1 and R7 occurred, evidence was insufficient to substantiate the allegation of inadequate supervision. The residents involved were separated after the incident and appropriate reports and care were documented.

The complaint involved allegations that staff failed to meet residents' toileting, hygiene, and timely assistance needs. The investigation included interviews with staff and residents, record reviews, and police documentation. The allegations were unsubstantiated due to lack of evidence.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents reported that assistance needs were met, and records showed that one resident (R1) sometimes refused care. Police documentation also found neglect and abuse allegations unfounded.

The complaint alleged that staff were unable to communicate with residents due to a language barrier. The complaint was investigated and found to be unsubstantiated.

The investigation found that although some staff are not fluent in English, they use tools like Google Translator and have English-speaking staff on each shift to communicate with residents. Interviews with residents and staff confirmed that language barriers did not interfere with communication. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff not ensuring resident privacy, inappropriate staff conduct, harassment, lack of supervision leading to resident altercations, failure to safeguard belongings, and inadequate food service. Interviews with residents and staff, review of surveillance footage, and facility tours did not support these claims.

The investigation found no preponderance of evidence to substantiate the allegations, which included privacy violations, inappropriate staff behavior, lack of supervision, safeguarding of belongings, and adequacy of food service. Surveillance video and interviews did not corroborate the complaints.

The complaint alleged staff stole $200 and a bag from a resident's room. The resident and staff gave conflicting accounts, and police found no evidence or witnesses. The allegation was unsubstantiated.

The investigation found conflicting statements about the alleged theft, with no evidence or independent witnesses to substantiate the claim. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff preventing the spread of lice, ensuring residents' bathing needs, and a resident threatening another. Interviews and file reviews did not provide sufficient evidence to confirm these allegations.

The investigation found no substantiated evidence to support the allegations. Staff and residents denied the lice outbreak and unmet bathing needs allegations, and the resident threat allegation was unsubstantiated based on interviews and file reviews.

The complaint alleged that the facility illegally evicted a resident without notice or reason. The investigation reviewed resident files, interviewed staff and the resident, and found the eviction notice was properly issued with reasons. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found that the facility had issued a 30-day eviction notice with reasoning for eviction dated 11/20/2023. Interviews and file reviews indicated the resident had behavioral issues and had been on a behavior contract. There was insufficient evidence to substantiate the allegation of illegal eviction, so the complaint was unsubstantiated.

The complaint involved three allegations: staff did not ensure a resident was clothed, did not ensure the resident had eaten, and did not check on the resident during the night. All allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The investigation found that although some allegations may have occurred, there was insufficient evidence to prove violations. Staff attempted to assist the resident with clothing and feeding, but the resident refused care. Night staff were present and provided care as needed, but the resident was non-compliant with care.

The complaint included allegations that a resident's room had no call light, resident needs were not met by staff, staff did not treat residents with dignity, and staff retaliated against a resident. All allegations were found unsubstantiated after interviews and observations.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the complaints, and observations confirmed residents had call light pendants and were treated with dignity. Resident #1 refused some assistance but was supported by staff and medical professionals.

The report discusses multiple topics including complaints history, resident placement compatibility, planned staff training, eviction procedures, and change of administration. No specific deficiencies or violations are detailed in the report.

The complaint alleged that on August 8, 2023, a resident was assaulted by a staff member named Salvador. The investigation revealed no staff by that name, surveillance footage did not support the allegation, and resident interviews did not corroborate the claim. The allegation was determined to be unsubstantiated.

The investigation found no evidence to substantiate the allegation that the resident was assaulted by a staff member named Salvador. Surveillance footage and staff rosters confirmed no such staff existed, and multiple residents and staff interviews did not corroborate the claim. No deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included improper hospice placement and inadequate care. The resident was confirmed to be receiving appropriate care from hospice and home health agencies, and the facility was not responsible for hospice admission.

The investigation found that the facility did not place the resident on hospice; the resident had a hospice referral prior to admission. The resident was receiving wound care services from home health and hospice agencies as appropriate. There was insufficient evidence to prove the alleged violations, so the allegations were unsubstantiated.

The complaint alleged inadequate supervision leading to a resident eloping on 09/05/2023. The resident was able to leave unassisted and returned on 09/08/2023. Proper reporting was made to authorities. The allegation was unsubstantiated.

The investigation found that although a resident left the facility unassisted without informing staff, the facility was properly staffed and provided adequate supervision. The allegation was unsubstantiated due to insufficient evidence to prove a violation.

The complaint alleged staff noncompliance with infection control practices causing a health and safety risk. Interviews with staff and residents, observations, and record reviews found no evidence to substantiate the allegation. The facility was following infection control policies and Pasadena Public Health Guidelines. No deficiencies were cited.

The investigation found that staff and residents denied the allegation and confirmed adherence to infection control policies. Observations and record reviews showed the facility was following COVID-19 precautions with sufficient PPE supplies and no current COVID cases, resulting in the allegation being unsubstantiated.

The complaint involved multiple allegations including failure to provide medical attention, refusal to provide breakfast, withholding towels, disrespectful treatment, and staff taking a resident's debit card. The investigation concluded all allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation found no substantiated evidence supporting the allegations that staff failed to provide medical attention, refused breakfast, withheld towels, disrespected residents, or took a resident's debit card. Interviews with staff and residents confirmed appropriate care and respect were provided.

The complaint alleged that facility staff did not safeguard residents' personal belongings. The allegation was unsubstantiated based on interviews, observations, and record reviews. Residents and staff denied the allegation, and no deficiencies were cited under California Code of Regulations Title 22.

The investigation found insufficient evidence to substantiate the allegation. Interviews with residents, staff, and a police officer, as well as record and policy reviews, indicated that residents' belongings were safeguarded and the facility had procedures and secured spaces for personal items.

The complaint investigation was unsubstantiated. Allegations included facility cleanliness, hygiene supplies, notification of dietary restrictions, record keeping, food quantity and quality, staff training, and use of universal precautions. Interviews, observations, and file reviews did not support the allegations.

The investigation found no sufficient evidence to substantiate the allegations. The facility was observed to be clean, adequately supplied with hygiene items, staff were aware of dietary restrictions, resident records were up to date, food quantity and quality were adequate, staff training was documented and sufficient, and universal precautions were properly followed.

The complaint investigation was unsubstantiated. Allegations included staff leaving a resident soiled, poor food quality, lack of assistance with showering and clothing, call button disrepair, improper urine container disposal, and disrespectful treatment. Interviews and observations did not support these claims.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff, facility tours, and document reviews did not corroborate claims of neglect or poor care, resulting in the allegations being unsubstantiated.

The complaint alleged that the facility placed a resident on hospice without meeting criteria and that the resident was not receiving needed care. The investigation included interviews and document reviews. The allegations were found unsubstantiated.

The investigation found that the facility did not place the resident on hospice; the resident had already been referred prior to admission. The resident was receiving wound care services as ordered, with home health and hospice agencies providing care at different times. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that the facility retaliated against a resident for filing a complaint, staff did not seek medical attention in a timely manner, and staff did not notify the resident's authorized representative of a change in condition. The investigation included interviews with residents and staff, and review of records. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The investigation found no sufficient evidence to substantiate the allegations. Interviews with residents and staff denied retaliation and failure to provide timely medical attention or notification to authorized representatives. The allegations were determined to be unsubstantiated.

The complaint was unsubstantiated based on interviews with staff and residents, observations of food availability and meal accommodations, and review of records. Residents and staff denied the allegations, and no evidence supported the claims.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews and observations indicated residents were adequately fed and received timely assistance when calling for help. No deficiencies were cited.

The complaint alleged that facility staff did not prevent a resident from being assaulted by another resident. The allegation was unsubstantiated based on interviews, review of records, and investigation findings.

The investigation found that although it was confirmed that one resident assaulted another, the facility took proper steps to address the situation. Interviews with staff and residents indicated efforts to de-escalate altercations and provide prompt assistance. There was insufficient evidence to substantiate the allegation.

The complaint alleged improper supervision of residents and inappropriate staff communication. Interviews with residents and staff, observations, and document reviews did not substantiate the allegations.

The investigation included interviews with residents and staff, observations, and record reviews. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, and no deficiencies were cited.

The complaint alleged that staff member S1 was providing medical care and signing physician's reports while their license was on probation. The allegation was unsubstantiated due to lack of evidence.

The investigation found no sufficient evidence to substantiate the allegation that staff member S1 was providing in-house medical care or signing physician's reports while on probation. Interviews with residents and staff, and review of medical records showed no direct medical care by S1 to residents.

The allegation of illegal eviction was unsubstantiated due to insufficient evidence. The resident was evicted after violating house rules and failing to pay rent, with an outstanding balance of $1,620.46.

The investigation found inconsistent statements and insufficient evidence to support the allegation of illegal eviction. The resident was issued a 30-day eviction notice for breaking house rules and failing to pay rent, and was evicted on 2023-04-27.

The complaint alleged lack of supervision leading to a resident altercation on 03/12/2022. The investigation included interviews and document reviews. The allegation was found unsubstantiated due to insufficient evidence.

The investigation found inconsistent statements and insufficient evidence to substantiate the allegation. Staff intervened immediately during the incidents, and no injuries or charges resulted. The allegation was determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to prevent resident altercations, illegal eviction, and lack of dignity in staff treatment. Evidence did not support these claims after review of surveillance, interviews, and documentation.

The investigation found insufficient evidence to substantiate the allegations. Surveillance video and interviews showed staff intervened promptly during resident altercations and applied first aid. The eviction was supported by documented violations and unpaid rent. There was no evidence staff treated the resident in an antagonizing manner.

The complaint investigation was unsubstantiated. Allegations included resident developing multiple pressure injuries, failure to prevent infection spread, retaining a resident requiring higher care, and inadequate wound care. The investigation reviewed medical records, staff and resident interviews, and physician input, concluding insufficient evidence to substantiate the allegations.

The investigation found no substantiated evidence to support the allegations. Staff and physician interviews, medical records, and observations indicated that residents did not develop pressure injuries while in care, infection control procedures were followed, no resident was retained requiring a higher level of care, and wound care was adequately provided.

The allegation was that staff did not notify the resident's authorized representative that the resident was missing. The investigation was unsubstantiated due to lack of preponderance of evidence. The resident's authorized representative was notified on 5/1/23, and police reports were filed on 5/1/23 as well.

The investigation found that the resident's authorized representative was notified in a timely manner and police reports were filed appropriately. There was insufficient evidence to substantiate the allegation, and no deficiencies were cited.

The complaint alleged that the facility was retaining residents who require a higher level of care. The allegation was unsubstantiated based on interviews with staff and review of resident records, including physician reports and preplacement appraisals.

The investigation found insufficient evidence to support the allegation. Interviews and record reviews indicated that residents in question did not require a higher level of care, and the allegation was unsubstantiated.

The complaint alleged staff financially abused a resident. The investigation included interviews with the administrator, staff, and residents, and review of resident files and documents. The allegation was found unsubstantiated due to lack of evidence.

The investigation found no preponderance of evidence to substantiate the allegation of financial abuse. Interviews and document reviews indicated the resident had taken out all his funds, and the facility provided additional funds to de-escalate the situation. No deficiencies were cited.

The complaint was unsubstantiated after investigation. The allegation was that facility staff mishandled residents' food items by requiring a resident to remove all food from kitchen storage within 24 hours. Staff explained food safety policies and offered temporary storage options. Residents confirmed they were unaware of the allegation and did not request kitchen staff to store outside food.

The investigation found insufficient evidence to substantiate the allegation. Staff and residents stated that outside food is not stored in the kitchen refrigerators to prevent cross-contamination, and residents were not aware of the alleged mishandling.

The allegation was that staff failed to provide a safe and comfortable environment for residents. The allegation was unsubstantiated after investigation.

The investigation found no preponderance of evidence to substantiate the allegation. Interviews with staff, case managers, program managers, and residents indicated that the facility was addressing resident safety and comfort concerns through meetings and increased supervision.

The allegation that a resident was not being provided mail was investigated and found to be unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegation. Staff and residents denied the claim, and mail distribution processes were observed to be secure and functioning properly.

The complaint alleged that a resident hit another resident with an object causing bruising. The allegation was investigated through interviews, document reviews, and video evidence. The complaint was found unsubstantiated due to lack of preponderance of evidence.

The investigation found that Resident 1 threw a chair at Resident 2 causing minor injury, law enforcement was involved, and Resident 1 was sent for a psychiatric evaluation. Despite the incident, there was insufficient evidence to substantiate regulatory violations, and the complaint was deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not cleaning resident rooms, not doing laundry timely, and not providing enough linens. Interviews with staff and residents, schedule reviews, and observations did not support the allegations.

The investigation found that resident rooms were cleaned regularly, laundry services were performed timely at least once a week, and residents were provided with sufficient linens. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included lack of call light in resident's room, unmet resident needs, staff disrespect, and retaliation. Interviews and observations did not support these claims.

The investigation found no preponderance of evidence to substantiate the allegations that the resident's room lacked a call light, residents' needs were unmet, staff treated residents without dignity, or staff retaliated against residents. All interviewed staff and residents denied the allegations.

The complaint investigation was triggered by multiple allegations including inadequate food service, unmet dietary needs, lack of toileting assistance, delayed response to calls, and failure to provide water. After interviews with staff and residents, review of records, and a kitchen tour, the allegations were found unsubstantiated.

The investigation found that staff provide adequate food service, meet residents' dietary needs, assist with toileting needs, respond timely to calls for assistance, and provide water to residents. The allegations were not corroborated by staff or resident interviews and were deemed unsubstantiated due to lack of preponderance of evidence.

The complaint involved three allegations: staff retaliating against residents for complaining, staff not ensuring residents do not smoke when oxygen is in use, and staff not ensuring privacy during phone calls. The allegations were found to be unsubstantiated due to insufficient evidence.

The investigation found insufficient evidence to substantiate allegations of staff retaliation and lack of privacy during phone calls. However, it was confirmed that a resident smoked indoors while using oxygen, but staff are monitoring and addressing the behavior. No deficiencies were cited.

The complaint alleged staff had inappropriate interactions with a resident. The investigation revealed the alleged individual was a visitor, not staff. The complaint was found to be unfounded and dismissed.

The investigation found that the alleged inappropriate interactions involved a visitor, not staff, and that the complaint was unfounded. Interviews with residents and staff did not corroborate the allegation, and the visitor was confirmed not to be an employee or volunteer.

The complaint investigation was unsubstantiated. Allegations included staff failing to intervene in a confrontation between residents, failure to protect resident privacy, and staff threatening eviction. Interviews with staff and residents, and review of records, did not support the allegations.

The investigation found insufficient evidence to substantiate the allegations. Staff intervened in resident altercations, ensured resident privacy by monitoring and redirecting residents, and did not threaten eviction but explained eviction consequences related to behavior and rent payment.

The complaint investigation was unsubstantiated. Allegations included disrepair of resident call buttons, unmet laundry and showering needs, facility dryer disrepair, and unmet bedding needs. Interviews with staff and residents, document reviews, and observations did not confirm these allegations.

The investigation found no substantiated evidence to support the allegations. Staff and residents denied the complaints, and observations confirmed that call buttons, laundry, showering schedules, dryer machines, and bedding services were functioning and provided as required.

The complaint alleged inadequate supervision of a resident resulting in wandering away from the facility. The allegation was unsubstantiated based on interviews and record review.

The investigation found no preponderance of evidence to prove the alleged violation occurred. Interviews and record reviews indicated the resident was able to leave the facility unassisted and did not have wandering behaviors. The allegation was unsubstantiated.

Complaint investigation was unsubstantiated. Allegations included resident developing multiple pressure injuries, staff not preventing infection spread, retaining residents needing higher care, and inadequate wound care. Evidence did not support these claims.

The investigation found no evidence that the facility caused pressure injuries or failed to prevent infection spread. The facility does not retain residents requiring higher levels of care and ensures proper wound care is provided, mostly by outside agencies. The allegations were unsubstantiated with no deficiencies or citations issued.