Complaint Investigation Report

The investigation consisted of the following:

On 02/10/2025, the department requested and gathered Resident 1’s (R1) records. On 02/25/2025, the department interviewed Witness 5 (W5) and Witness 9 (W9). On 03/12/2025, the department interviewed Staff 1 (S1), Staff 2 (S2), Witness 10 (W10). The department interviewed/attempted to interview R1, Resident 11 (R11), Resident 19 (R19) and Resident 20 (R20). On 06/25/2025, the department interviewed W5 and Witness 11 (W11). On 10/16/2025, the department interviewed/attempted to interview residents, staff, and witnesses. The department interviewed/attempted to interview Resident 2 (R2) to Resident 18 (R18); R2 to Resident 10 (R10) were able to answer all questions; Resident 11 (R11) to Resident 12 (R12) were able to answer some questions; and Resident 13 (R13) to R18 were unable to answer questions. The department interviewed Staff 1 (S1) to Staff 5 (S5) and attempted to interview Staff 6 (S6). The department interviewed Witness 1 (W1) to W5 and attempted to interview W6 to Witness 14 (W14). Facility records were gathered and reviewed which consisted of Personnel Report dated 10/15/2025, Resident Roster, and Identification And Emergency Information records for R2 to R11. On 10/29/2025, the department interviewed/attempted to interview staff and witnesses. The department attempted to interview S6. The department interviewed W6 to Witness 8 (W8) and attempted to interview Witness 9 (W9) to W14.