complaint·March 12, 2025

The investigation revealed the following: Allegation #1-Staff does not award resident privacy. The details of the complaint alleged that the facility staff keeps unlocking the residents’ room when they are not present to get the resident upset. On 3/12/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff does not award resident privacy. Staff (S1-S4) stated that they do not violate the residents right to privacy. They state that all residents have a right to their privacy and are made aware of their rights once they move into the facility. The Department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that the Staff does not award resident privacy. The majority of the residents interviewed (9 of 10) stated that the staff does give them their privacy and does not have an issue with their personal rights being violated because of a lack of privacy. 9 of 10 residents further state that they have not had a problem with staff leaving their bedroom doors unlocked. The Department reviewed In-Service Staff Training (Dated: 9/14/21-12/23/24) and observed that the staff has training in Personal Rights, Abuse, Neglect of Residents, Ethics and Caring, Skills for Effective Communication, and Cultural Diversity. Additionally, the department reviewed a sampling of residents’ files and observed that each file reviewed contained Personal Rights (Dated: 3/20/12, 5/22/23, 10/16/24, 8/18/16, & 8/20/18) documents signed and acknowledged by the residents. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff does not award resident privacy. 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 . Allegation #2- Staff does not treat resident with respect. The details of the complaint alleged that the facility staff does not treat the resident with dignity and respect because of concerns the resident raised and that are still on-going without resolution. On 3/12/25, from 10:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. Staff (S1-S4) denied the allegation that the Staff does not treat resident with respect. All staff (S1-S4) stated that the facility does treats all their residents with dignity and respect and try to foster an atmosphere of respect and inclusion. They further state that the personal rights and well-being of their residents is a high priority. The Department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not treat resident with respect. The majority of residents that were interviewed (9 of 10) stated that the facility does treat them with dignity and respect and are happy living at the facility. Page 2 of 3 The Department reviewed In-Service Staff Training (Dated: 9/14/21-12/23/24) and observed that the staff has training in Personal Rights, Abuse, Neglect of Residents, Ethics and Caring, Skills for Effective Communication, and Cultural Diversity. Additionally, the department reviewed a sampling of residents’ files and observed that each file reviewed contained Personal Rights (Dated: 3/20/12, 5/22/23, 10/16/24, 8/18/16, & 8/20/18) documents signed and acknowledged by the residents. The department further observed during the interview process, that the residents are aware of their personal rights and a majority stated that their rights have not been violated because of a lack of respect given to them by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff does not treat resident with respect. 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 citations were issued. An exit interview was conducted with Jenni Gordon, Administrator, and a hard copy of this Complaint Investigation Report was provided. Page 3 of 3 Complaint Investigation Report