Complaint Investigation Report

In regard to the allegation “Facility staff retaliated against resident for filing a complaint”, it is alleged that R1 was put on a 5150 hold for making a complaint against facility. During interviews with residents nine (9) out of ten (10) residents stated staff has never retaliated or treated them poorly for filing a complaint or doing something staff doesn’t agree with. During interviews with staff six (6) out of six (6) stated they have never retaliated against residents for filing a complaint. Administrator stated that a 5150 hold was placed on R1 because of aggression only after being evaluated by the clinician.

In regard to the allegation “Facility staff refused resident re-entry resulting in a forced eviction”, it is alleged that when R1 was released from hospital R1 was refused entry to facility. During interviews with residents nine (9) out of ten (10) residents stated that they have never been denied re-entry into the facility. During interviews with staff six (6) out of six (6) staff stated R1 was not denied re-entry to facility. Administrator stated that R1 is conserved and conservator made the decision to move R1 to another facility. R1 was never evicted. LPA obtained a copy of Acknowledgment of Discharge signed 10/31/2025 by R1’s conservator. No evection letter was ever issued to R1.

In regard to the allegation “Facility staff did not ensure inventory of residents personal belongings were maintained”, it is alleged that R1 had accumulated more inventory and inventory was never taken. During interviews with residents nine (9) out of ten (10) residents stated staff does ask residents to update inventory list when new items are brought in. Residents stated that staff helps them to update list. During interviews with staff six (6) out of six (6) stated they remind residents that inventory list needs to be updated. S3 stated that front desk will stop residents if they see them coming in with something to update their list. Staff stated that it is both the responsibility of staff and residents to ensure the list is updated. During record review LPA obtained copies of inventory list of R1’S belongings. LPA obtained pictures of R1’s belongings packed in multiple black trash bags and a signed letter of personal belongings being removed by R1’s conservator dated 10/31/2025.