Complaint Investigation Report

Regarding the allegation that staff did not provide a safe environment for residents, it was alleged that while staff were attempting to prevent R1 from leaving the facility, a staff member pulled R1’s arm, causing R1 to be pushed down and roll onto the pavement. LPA’s interview with staff on 01/08/2026 revealed that the volunteer advocate was the individual pulling R1 away from staff and was reportedly yelling and physically striking staff during the incident.

Regarding the allegation that staff denied R1 access to personal belongings, it was alleged that staff refused to provide R1 with medication and personal belongings. LPA’s interview with staff on 01/08/2026 revealed that R1 arrived at and was admitted to the facility from a Skilled Nursing Facility with only the clothing R1 was wearing. Staff reported that the facility obtained the additional belongings that R1 possessed when leaving the facility. LPA’s interview with the Administrator today at 11:36 a.m. further revealed that although the Administrator was not physically present at the facility during the incident, she remained on the phone with staff throughout the event and confirmed that all of R1’s belongings and medications were provided to R1 upon departure.

Regarding the allegation that staff did not communicate with R1 regarding care, it was alleged that staff moved R1 to another room without first consulting R1. LPA’s interview with staff on 01/08/2026 revealed that R1 had requested the room change in order to share a room with Resident #2 (R2). LPA’s interview with R2 today at 12:13 p.m. confirmed that R1 had requested to room with R2. Further interview with R2 revealed that R1 appeared happy while residing at the facility and later told R2, when R2 encountered R1 near the facility, that R1 would have preferred to remain at the facility. According to R2, the issue was that R1 was unable to consume alcohol at the facility, unlike at R1’s current residence.

Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated.

An exit interview was conducted and a copy of this report was given.