Inspection Reports for
Kingsley Manor

The complaint involved two allegations: 1) Staff threatening resident #1 with eviction if payment was not made, and 2) Staff having resident #1 sign a document without an authorized representative present. The investigation included interviews, document reviews, and observations. The allegations were found unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegations. Staff and residents denied the claims of threats and improper document signing. Resident #1 was found to be self-responsible and able to sign documents without a representative. The eviction notice issued complied with regulations. The allegations were unsubstantiated.

The complaint involved two main allegations: 1) Staff threatening resident 1 (R1) with eviction over unpaid fees and additional charges related to preventing elopement, and 2) Staff having R1 sign a document without the resident's authorized representative present. Both allegations were investigated through interviews, document review, and observations and were found to be unsubstantiated.

The investigation found no substantiation for the allegations. Interviews with residents and staff, document reviews, and observations indicated that the facility's actions were appropriate, and residents denied the allegations. The facility's notice regarding unpaid fees was not considered a threat, and the resident was found to be self-responsible and able to sign documents.

The complaint alleged that the facility charged a resident for unnecessary services without informing or obtaining consent from the resident's responsible party. The investigation included interviews with residents, staff, and the resident's family, as well as document reviews. The resident was found to be self-responsible and receiving the services charged for, following a reassessment after an elopement incident. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the resident was receiving additional services related to a reassessment after an elopement incident, including frequent wellness checks and a monitoring bracelet. Although the allegation was made, there was insufficient evidence to prove the violation, and the allegation was unsubstantiated.

Resident 1 alleged that staff 1 inappropriately touched them on 2025-09-07. Licensing Program Analysts interviewed resident 1 and reviewed relevant records. No deficiencies or severity levels were documented in the report.

Licensing Program Analysts conducted a physical plant tour and did not observe any health and safety risks to residents. Records for resident 1 and staff 1 were reviewed, and R1 was interviewed regarding the allegation.

Resident 1 alleged that staff 1 inappropriately touched them on 2025-09-07. Licensing Program Analysts interviewed resident 1 and reviewed relevant records as part of the investigation.

The Licensing Program Analysts conducted a physical plant tour and did not observe any health or safety risks to residents. They reviewed records of resident 1 and staff 1 and interviewed resident 1 regarding the allegation.

The complaint alleged that Resident #1 pushed Resident #5, became aggressive, yelled at other residents, hit the table, and threw a soda at another resident. Interviews with staff, residents, and review of documentation found no corroborating evidence. Staff were reported to have intervened appropriately and residents denied the allegations. The complaint was unsubstantiated.

The investigation included interviews with residents, staff, and review of records. The evidence was insufficient to substantiate the allegation that staff failed to intervene appropriately during incidents involving residents. The allegations were determined to be unsubstantiated.

The facility was found to be in compliance with all licensing requirements with no deficiencies cited. Infection control practices, safety measures, staffing, food service, and resident care were all observed to meet regulatory standards. A technical violation was issued.

The facility was found to have appropriate infection control plans, operational requirements, physical plant safety, staffing, personnel training, resident rights information, food service, medical and dental care, and disaster preparedness. No deficiencies were cited, but a technical violation was issued.

The complaint alleged that the facility charged a resident for additional services without informing or obtaining consent from the resident's responsible party, and that the additional fee was not listed in the admission agreement. The investigation included interviews, document reviews, and observations, concluding the allegation was unsubstantiated.

The investigation found that the resident was receiving the services identified by a re-assessment to prevent eloping, and that seven out of eight residents denied the allegation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility charged a resident for additional services without informing or obtaining consent from the resident's responsible party. The investigation included interviews with staff and the resident, document review, and observations. The allegation was determined to be unsubstantiated.

The investigation found that the resident was receiving services as identified by a health reassessment following an incident of eloping. Documentation and interviews indicated that the additional fees were related to these services, and the allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff negligence causing damage to a resident's denture container and failure to follow infection control guidelines. Interviews and observations did not provide a preponderance of evidence to prove the allegations.

The investigation found insufficient evidence to substantiate the allegations. Staff and most residents denied the claims, and observations showed staff following infection control practices. Therefore, both allegations were unsubstantiated and no violations were cited.

The complaint was unsubstantiated. Allegations included staff negligence causing damage to a resident's denture container and failure to follow infection control guidelines. Interviews and observations did not support these allegations.

The investigation found insufficient evidence to substantiate the allegations. Staff and most residents denied the claims, and observations showed staff following infection control practices. No violations were cited.

The Licensing Program Analyst conducted a health and safety check and interviews with staff and family members. No signs of neglect, abuse, or immediate health and safety threats were observed during the visit.

The Licensing Program Analyst conducted a health and safety check and interviews, reviewed relevant documents, and found no signs of neglect, abuse, or other immediate health and safety threats during the visit.

The complaint was unsubstantiated. Allegations included illegal eviction of resident R1 and confiscation of R1's walker. Evidence reviewed included notices, interviews, and witness statements. The investigation concluded there was no preponderance of evidence to prove the alleged violations.

The investigation found insufficient evidence to substantiate the allegations of illegal eviction and confiscation of belongings. Staff and residents interviewed denied the allegations, and no deficiencies were cited.

The complaint involved allegations that staff illegally evicted a resident and confiscated the resident's walker. The investigation was unsubstantiated due to lack of preponderance of evidence.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and no deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included staff not properly positioning a resident, not meeting toileting needs, and a resident developing pressure injuries. Interviews with eight residents and staff, as well as record reviews, did not support these claims.

The investigation found no corroboration for the allegations after interviews with residents and staff, record reviews, and observations. Staff were found to assist residents appropriately, and no pressure injuries were identified. The allegations were determined to be unsubstantiated due to lack of evidence.

The complaint investigation was unannounced and initiated based on a complaint received on 07/29/2024. The allegations included improper resident positioning, unmet toileting needs, and development of pressure injuries. The investigation concluded the allegations were unsubstantiated.

The investigation found no corroboration for the allegations after interviews with residents and staff, record reviews, and observations. All allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The facility was found to be in compliance with no deficiencies observed. The inspection covered multiple domains including infection control, physical plant safety, staffing, personnel records, client rights, food service, and disaster preparedness. Fire clearance was approved and emergency drills were up to date.

The facility was inspected across multiple domains including infection control, physical plant safety, staffing, personnel records, client rights, food service, and disaster preparedness. No deficiencies were observed during the visit.

The complaint alleged that Resident #1's death was caused by neglect from Staff #1 who did not check on the resident during the overnight shift. Interviews and record reviews showed staff failed to provide supervision, but no causal link to death was found. The allegation was unsubstantiated.

The investigation found that two staff members failed to provide supervision to Resident #1 during their shifts, resulting in the resident falling and sustaining injuries. However, there was no evidence to establish a causal link between the failure to conduct timely rounds and the resident's death, which was ruled an accident by the Medical Examiner. The allegation was determined to be unsubstantiated.

The complaint alleged that Resident #1's death was caused by neglectful staff. The investigation included interviews with staff, family, and residents, and review of medical and emergency reports. Despite staff failing to check on the resident as required, there was no preponderance of evidence to prove the alleged violation, resulting in an unsubstantiated finding.

The investigation found that two staff members failed to provide supervision to the resident during their shifts, but there was no evidence linking this failure to the resident's death. The death was ruled an accident by the Medical Examiner, and the allegation was unsubstantiated.

The complaint involved allegations that facility staff did not keep the facility free of obstructions, spoke inappropriately to residents, did not treat residents with respect and dignity, and failed to safeguard resident property. After investigation, all allegations were determined to be unsubstantiated.

The investigation included interviews with staff and residents, a tour of the facility, and document reviews. All allegations, including staff not keeping the facility free of obstructions, inappropriate speech, lack of respect and dignity, and failure to safeguard resident property, were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that staff did not keep the facility free of obstructions, spoke inappropriately to residents, did not treat residents with respect and dignity, and failed to safeguard resident property. After investigation, all allegations were determined to be unsubstantiated.

The investigation included interviews with staff and residents, a tour of the facility, and document reviews. All allegations including staff not keeping the facility free of obstructions, speaking inappropriately to residents, not treating residents with respect and dignity, and not safeguarding resident property were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that facility staff were interfering with the resident council by changing the policy on distribution of the employee appreciation fund. The investigation included interviews with residents, staff, and corporate representatives. The allegation was found to be unsubstantiated due to lack of evidence.

The investigation found no evidence that the facility was interfering with the resident council. The issue was related to a corporate policy change on how the Employee Appreciation Fund is handled, which residents and staff were notified about. The allegation was unsubstantiated.

The complaint alleged that facility staff were interfering with the resident council by changing the policy on distribution of the employee appreciation fund. The allegation was unsubstantiated after interviews with residents, staff, and corporate representatives, and review of relevant documents.

The investigation found no evidence that the facility was interfering with the resident council meeting. The policy change regarding the employee appreciation fund was made by the corporate office and communicated to residents and staff. The allegation was determined to be unsubstantiated.

The complaint alleged that the facility would not accept monthly rent payments from a resident. The allegation was unsubstantiated after investigation. It was confirmed that an eviction notice and unlawful detainer were issued to the resident, and the facility was legally advised not to accept payments. The resident wanted the facility to obtain payment from the Assisted Living Waiver program, but that program does not cover rent or board and care fees.

The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated. Staff interviews and document reviews confirmed an eviction notice and unlawful detainer were issued, and the facility was legally advised not to accept payments from the resident.

The complaint alleged that the facility would not accept monthly rent payments from Resident #1. Staff interviews confirmed an eviction notice and unlawful detainer were issued, and the facility was legally advised not to accept payments. Resident #1 wanted the facility to obtain payment from the Assisted Living Waiver program, which does not cover rent. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the facility refused to accept monthly rent payments from Resident #1 due to an unlawful detainer filed against the resident and legal advice to not accept payments. However, there was insufficient evidence to prove the alleged violation occurred, and the allegation was determined to be unsubstantiated.

Personnel records were reviewed including criminal background clearance and training for nine staff members. Health related services include assistance with self-administration of medications and proper storage of centrally stored medications. Emergency preparedness was verified with a posted Emergency Disaster Plan and recent emergency drill and fire alarm checks documented.

Personnel records and staff training were reviewed and found to be in compliance, including criminal background clearance and required certifications. Health-related services such as medication administration were properly managed, and disaster preparedness measures including emergency plans and drills were observed.

The complaint alleged that resident (R1) was being financially exploited by resident (R2), who requested a transfer of stock shares owned by R1. The investigation included interviews with 16 residents, 4 staff, private caregiver, and family members, as well as review of resident files and physician reports. Resident (R1) denied abuse and was oriented to person, place, and situation. Resident (R2) denied abuse and stated the transfer was a mutual decision. No financial interests had been transferred due to lack of authorization. The allegation was unsubstantiated due to insufficient evidence.

The investigation found insufficient evidence to substantiate the allegation of financial abuse between residents. Interviews with residents, staff, and family members, as well as document reviews, indicated that the alleged financial transfer had not occurred and the resident denied abuse. The allegation was determined to be unsubstantiated.

The complaint alleged that resident (R1) was being financially exploited by resident (R2), who requested transfer of stock shares owned by R1. The investigation included interviews with 16 residents, 4 staff, private caregiver, and family members, and review of resident files. Both residents denied financial abuse. The facility had notified family of Power of Attorney changes and followed protocol for reporting suspected abuse. There was no physician capacity declaration or conservatorship for R1. The allegation was unsubstantiated due to insufficient evidence.

The investigation found insufficient evidence to substantiate the allegation of financial abuse between residents. Interviews with residents, staff, and family members, as well as document reviews, indicated that the alleged financial exploitation was not proven, and the allegation was deemed unsubstantiated.

The complaint alleged staff were not following a resident's dietary needs. After interviews with residents and staff, and a tour of the kitchen and dining areas, the allegation was found unsubstantiated.

The investigation found that residents and staff reported no ongoing issues with dietary needs. The facility provides special menus and replacement meals as needed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff were not following a resident's dietary needs. The investigation included interviews with residents and staff, review of dietary menus, and a kitchen tour. The allegation was found to be unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegation. Interviews with residents and staff indicated that dietary needs were being met, including special menus and replacement meals. The allegation was determined to be unsubstantiated.

The complaint involved allegations that staff spoke inappropriately to residents, failed to treat residents with dignity and respect, and failed to provide a comfortable environment. The investigation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that staff communicated politely and professionally with residents, treated residents with dignity and respect, and provided a comfortable environment. Interviews with residents and staff did not substantiate the allegations.

The complaint investigation was unsubstantiated. Allegations included inappropriate speech by staff, failure to treat residents with dignity and respect, and failure to provide a comfortable environment. Interviews and evidence did not support the allegations.

The investigation included interviews with the administrator, staff, and residents, and review of rosters. The allegations were found to be unsubstantiated as most residents reported respectful treatment and a comfortable environment, and staff denied inappropriate behavior.

The complaint alleged financial abuse of a resident. The Power of Attorney reported withdrawals over $1250 in two months, but stated the facility did not do any wrongdoing. The resident confirmed the facility did not touch his money and spends money at casinos. The allegation was unsubstantiated.

The investigation included interviews with the resident, staff, and administrator, as well as a review of relevant documents. It was found that the resident spent his own money gambling and the facility did not have access to his funds. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged financial abuse of a resident. The Power of Attorney reported withdrawals of over $1250 in two months. Interviews and document reviews showed the resident managed his own money and spent it gambling. The allegation was unsubstantiated.

The investigation included interviews with the resident, staff, and administrator, as well as a review of relevant documents. It was found that the resident spent money gambling and the facility did not have access to the resident's funds. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included a resident injury from a fall, a resident exhibiting threatening behavior and intoxication, and staff performing duties without proper qualifications. Investigators reviewed incident reports, interviewed staff and residents, and reviewed training and physician reports. No preponderance of evidence was found to prove violations.

The investigation found insufficient evidence to substantiate the allegations. The resident injury allegation was unsubstantiated despite documentation of a fall and hospitalization. The allegation of a resident threatening others was unsubstantiated after review of incident reports and resident removal. The allegation that staff did not meet qualifications was also unsubstantiated based on interviews and training documentation.

The complaint investigation was unsubstantiated. Allegations included a resident injury from a fall, a resident exhibiting threatening and aggressive behavior leading to eviction, and staff performing duties without proper qualifications. Interviews, document reviews, and observations did not provide sufficient evidence to prove violations occurred.

The investigation found insufficient evidence to substantiate the allegations. The resident injury allegation was unsubstantiated due to lack of preponderance of evidence. The resident threatening safety allegation involved documented incidents and eviction, but was also unsubstantiated. The allegation that staff did not meet qualifications was unsubstantiated as staff received appropriate training and residents felt staff were qualified.

The facility was found to be in compliance with all applicable regulations, including fire safety, staffing, medication management, and environmental conditions. No deficiencies were observed during the visit.

The complaint included allegations that staff did not provide proper assistance to a resident, were not mitigating the spread of pests, and were not following COVID-19 protocols. The investigation included interviews with staff, residents, pest control technician, and public health nurse. The allegations were determined to be unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to assist residents appropriately, pest control measures were in place and effective, and COVID-19 protocols were generally followed with some resident noncompliance.

The complaint investigation was unsubstantiated. Allegations included staff not providing proper assistance to a resident, failure to mitigate pest spread, and not following COVID-19 protocols. Interviews with staff, residents, pest control technician, and public health nurse supported that the facility addressed these concerns adequately.

The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to assist residents appropriately, pest control measures were in place and effective, and COVID-19 protocols were generally followed with some resident non-compliance.

The facility was found to be in compliance with all applicable regulations, including fire safety, staffing, medication management, and environmental conditions. No deficiencies were observed during the visit.

The complaint alleged the facility had not repaired a leaking air conditioner. The allegation was unsubstantiated after investigation.

The investigation found that five out of five staff denied the allegation and four out of four residents reported no issues with their air conditioning units. Observations confirmed that resident window air conditioning units were operational. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated. The allegation was that the facility had not repaired a leaking air conditioner. Staff and residents denied the issue, and observations supported this. There was no preponderance of evidence to prove the violation occurred.

The investigation found that five out of five staff denied the allegation and stated they attempt to fix or replace malfunctioning air conditioning units within a few days. Four residents interviewed denied any issues with their air conditioning units. Observations confirmed that air conditioning units in several resident rooms were operational. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff failing to return resident's personal belongings, treating residents without dignity and respect, engaging in verbal altercations, and failing to meet residents' needs. Interviews with seven residents and eight staff members did not corroborate any allegations.

The investigation included interviews with staff and residents, record reviews, and a facility tour. All allegations were found to be unsubstantiated as interviews and evidence did not corroborate the complaints.

The complaint investigation was unsubstantiated. Allegations included staff failing to return resident's personal belongings, treating residents without dignity and respect, engaging in verbal altercations, and failing to meet residents' needs. Interviews with seven residents and eight staff members did not corroborate any of the allegations.

The investigation included interviews with staff and residents, record reviews, and a facility tour. All allegations were found to be unsubstantiated as interviews and evidence did not corroborate the complaints.

The complaint involved a fall incident of Resident #1 on 11/20/2022, with injuries including a fractured left knee and right wrist. The complaint was investigated and found to be unsubstantiated with no neglect or lack of supervision.

The investigation found that Resident #1 had an accidental ground level fall resulting in fractures but no signs of neglect or lack of supervision were identified. No deficiencies were issued.

The complaint involved a resident who fell and sustained injuries including a fractured left knee and right wrist. The resident was found promptly by nursing staff, and the investigation concluded no neglect or lack of supervision.

The investigation found no signs of neglect or lack of supervision related to the resident's fall. The resident was independent with a 1:1 caregiver and had access to emergency alert devices. No deficiencies were issued.

The complaint alleged that staff were not meeting residents' showering needs. The investigation included interviews with the resident, staff, and administrator, and review of relevant schedules and agreements. The allegation was found unsubstantiated.

The investigation found that staff assisted the resident with all showering needs on 11/13/2022 and that the resident prefers showering once a week on Sundays. A meeting was scheduled to discuss the matter further. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff were not meeting residents' showering needs. The allegation was unsubstantiated after investigation.

The investigation found that staff assisted the resident with all showering needs on 11/13/2022 and that the resident prefers showering once a week on Sundays. A meeting was scheduled with the resident, family, social worker, and ombudsman. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged illegal eviction of resident #1. Interviews with residents and staff, as well as document reviews, showed that eviction procedures followed required regulations and that the resident had not complied with payment requests since November 2021. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the eviction notices issued to the resident were lawful and in compliance with regulations. Despite the resident's claim, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The complaint alleged illegal eviction of resident #1. The resident was still residing at the facility and claimed the eviction procedure was illegal. Staff and other residents denied the allegation. Documentation showed proper eviction notices were issued. The allegation was determined to be unsubstantiated.

The investigation found that the eviction procedure for resident #1 was lawful and in compliance with regulations. The allegation was unsubstantiated due to lack of preponderance of evidence despite the resident's claim.

The complaint investigation was unsubstantiated. Allegations included neglect/lack of care regarding assistance with showering and medication administration. Interviews, record reviews, and evidence showed no preponderance to prove the alleged violations occurred.

The investigation found that Resident #1 was independent in self-care and medication management, refused facility care services, and had left the facility following hospitalization. There was insufficient evidence to substantiate the allegations, and both were found to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included neglect/lack of care regarding assistance with showering and medication administration. Evidence and interviews did not prove the alleged violations occurred.

The investigation found that Resident #1 was independent and responsible for their own care, including bathing and medication management. The resident refused facility care and did not return after hospitalization. There was insufficient evidence to prove the allegations; therefore, both allegations were found to be unsubstantiated.

The complaint involved an allegation by Resident #1 that someone entered their room and touched their private part, but the resident could not identify the person or the time of the incident. Subsequent interviews indicated a misunderstanding and no substantiated memory of the event by the resident.

Interviews and investigation revealed that Resident #1 did not remember the alleged incident and no other allegations were reported. The Licensing Program Analyst found no deficiencies cited during the visit.

The complaint involved an allegation by Resident #1 that someone entered their room and touched their private part. The resident could not identify the person or time. Staff interviews indicated no confirmation of the allegation, and R1 acknowledged no memory of the incident. The complaint was not substantiated.

Interviews with staff and R1 revealed inconsistencies and possible misunderstandings about the incident. R1 did not remember being touched, and no other allegations were reported. The Executive Director confirmed the resident was doing well. No deficiencies were cited during the visit.

The visit was triggered by the incident and death of a resident on June 26, 2022. The resident was pronounced dead at the scene after falling from the 5th floor balcony. The facility was instructed to submit the Death Certificate and Coroner's report.

The resident was found deceased after falling from the 5th floor balcony. The facility provided notification to the licensing division and relevant documents were obtained for review.

The resident was found deceased outside the building after falling from the 5th floor balcony. The balcony railing was approximately 36 inches high. The facility notified the Community Care Licensing Division and provided relevant documents for review.

The complaint involved allegations that staff failed to prevent a resident from engaging in inappropriate behaviors and failed to provide a safe environment. The resident was physically violent, damaged property, and caused distress among other residents. Staff and management reported efforts to manage the resident's behavior, including police involvement and attempts to evict the resident. Interviews with staff, residents, and family members supported that staff acted appropriately. The complaint was unsubstantiated due to lack of sufficient evidence.

The investigation found that although a resident (R4) exhibited aggressive and inappropriate behaviors causing concern among residents, staff took actions to redirect and keep residents safe, including calling police when necessary. Interviews with staff, residents, and family members indicated that the facility provides a safe environment and prevents inappropriate behaviors. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint was unsubstantiated. Allegations involved staff failing to prevent a resident from inappropriate behaviors and failing to provide a safe environment. The resident in question exhibited aggressive behaviors, and staff took steps to manage the situation including police involvement. Interviews and observations did not support the allegations.

The investigation found that a resident (R4) exhibited aggressive and inappropriate behaviors, including physical violence and property damage, causing concern among other residents. Staff and management stated they take measures to redirect and control the resident's behavior, including calling police when necessary. Interviews with staff, residents, and family members indicated that the facility provides a safe environment and staff actively prevent inappropriate behaviors. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint alleged that a resident was raped by a staff member. Interviews revealed cognitive impairment of the resident and no corroborating evidence was found. Family members and staff denied neglect or abuse. Hospital records showed no trauma or complaints. The allegation was unsubstantiated due to lack of evidence.

The investigation included interviews with residents, family members, caregivers, and review of hospital medical records. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.

The complaint alleged that a resident was raped by a staff member. Interviews revealed cognitive impairment of the resident and lack of specific details. Family members and staff denied the allegation. Hospital records showed no trauma or complaints. The allegation was unsubstantiated due to insufficient evidence.

The investigation included interviews with residents, family members, caregivers, and review of hospital medical records. No sufficient evidence was found to substantiate the allegation, and the complaint was determined to be unsubstantiated.