complaint·September 3, 2024

The investigation revealed the following: In regards to the allegation: "Staff pushed resident out of their wheelchair while in care." It is alleged that R1 was pushed out of her wheelchair. No other information provided. Interviews conducted with (5) of (5) staff all denied the allegation. Staff interviewed indicated that they have never pushed any resident, nor have they observed any other staff push any of the residents out of their wheelchair. Staff stated that if they observe residents needing help, they assist in pushing the residents' wheelchair with their consent. (10) of (10) residents interviewed denied the allegation and indicated that staff treat them with dignity, and they feel safe at the facility. (5) out of (10) interviewed residents use wheelchair and stated that they were never pushed out of their wheelchair nor observed any staff push any of the residents out of their wheelchair. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: “Staff locked resident in their room while in care.” It is alleged that R1 was locked into the room and that staff would tie the bedroom's doorknob to a metal railing with a sheet so R1 could not get out, and was left there for hours. (5) out of (5) staff interviewed denied the allegation. Staff interviewed stated that they would never lock any resident in their bedroom as it is against the law and a violation of the residents rights. (10) out of (10) interviewed residents denied the allegation. Interviewed residents stated that they have never been locked in their bedrooms by staff nor have seen any other residents being locked in their bedrooms. During the visit, LPA tested R1's bedroom door lock and observed that R1's bedroom cannot be locked from the outside. LPA also observed that there is a sliding door in R1's bedroom that leads to the back patio area and can be used as entrance/exit to R1's bedroom. Additionally, LPA did not observe any metal railing near R1's bedroom door. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: "Staff did not safeguard resident's personal belongings while in care." It is alleged that the facility staff kept R1's belongings and was only given (5) bags of donated clothes when R1 left the facility. (5) out of (5) staff interviewed denied the allegation. S1 stated that if a resident leave the facility for a long period of time, the residents' belongings are kept in their bedrooms until they get confirmation that the resident is not coming back to the facility. Staff indicated that they pack, label, hold and store the residents' belongings in the storage room until the resident or family member is ready to pick them up. (10) out of (10) interviewed residents stated that they do not have any issues with their personal belongings. Interviewed residents indicated that they feel that their personal belongings are safe in their bedrooms. Reviewed documentation showed that upon moving in, R1 waived her right to complete a personal inventory list. Documentation reviewed and interviews conducted do not corroborate this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may h ave happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to Alexander Solorio, Assistant Administrator.