Complaint·February 6, 2025

Interviews with care staff (S1 – S6), including those who have worked closely with R1, consistently described R1 as a kind person who does not have malicious intent towards others. Staff members reported that R1’s actions were largely a result of their cognitive impairments and confusion, which led R1 to occasionally enter other residents' rooms by mistake or engage in disruptive behaviors, like shouting. R1’s inability to remember basic facts and their tendency to wander were contributing factors to their confusion. Additionally, interviews did not indicate that R1 had physically harmed or verbally abused other residents with intent. Interviews also revealed that R1 had a history of confusion with room locations, particularly with a Resident2 (R2), who had previously complained about R1 entering their room. However, R2 had relocated to another part of the facility, and since that move, there had been no further complaints. Also staff had stated that they actively worked to manage R1’s behaviors by providing constant supervision and assistance with activities of daily living (ADLs), including showering, meals, and ensuring R1’s safety while wandering the facility. Although R1’s behaviors were occasionally disruptive, there was no evidence that staff ignored or failed to address these issues. Staff were aware of R1’s condition and took measures to offer R2 another location to move to within the facility. Based on the information gathered, the allegation that staff are not preventing R1 from harassing other residents in care was found to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. Exit interview was conducted with Susan McClure and a copy of this report and appeal rights were provided. {2 of 2}