complaint·July 24, 2025

On 7/14/2025, LPA Lindstrom interviewed three Staff (S1, S2, and S3). S1 stated that wheelchair brakes were never applied for staff convenience, only for safety during meals, transfers, and group activities. S1 stated that staff were always present during these times to release the brakes when residents wanted to leave. S2 stated that staff applied wheelchair brakes at the dining room tables to prevent wandering and during group activities to keep residents in place. S3 stated that staff was not supposed to lock wheelchairs; staff let residents have free will. On 7/16/2025, LPA Lindstrom interviewed three Staff (S3, S4, and S5). S3 stated that staff locked one wheelchair brake during meals to reduce fall risks. S3 explained that one unlocked brake allowed residents to still self propel, which let staff know they wanted to leave. S4 stated that wheelchair brakes should be locked during resident transfers to and from wheelchairs. S5 stated that brakes were not to be used except for safety during meals, activities, and dangerous situations. On 7/16/2025, the LPA interviewed two Residents in wheelchairs (R1 and R2). R1 stated that he had gotten all the help he needed from staff with his wheelchair and that he had no complaints. R2 stated that he got the assistance he needed from staff with his wheelchair. On 07/16/2025, LPA Lindstrom observed four residents in wheelchairs watching a movie and eight residents in wheelchairs singing together in a group activity, all with no brakes applied. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.