Complaint Investigation Report

Allegation: Staff prevents residents from using the public restroom by locking the doors. The complaint alleges that in early July 2025 the community/public 1st floor restroom was being locked so that staff had less of restroom assignments because at that time there was only one housekeeper in the building. It is alleged that a resident informed staff that the 1st floor restroom was locked, the resident was told to go upstairs to use the restroom in their room, and the inaccessibility and closure of the 1st floor public restroom caused the resident to have a couple of incontinence accidents on two different occasions. A total of 11 residents were interviewed. Seven (7) out of 11 residents confirmed the allegation. Resident interviews revealed that they were told by staff the 1st floor restroom was locked because residents were falling in the restroom. Residents said that some residents had incontinence accidents because they were not allowed to use the 1st floor restroom. The restroom closure affected residents in care and their visitors. A total of 13 staff were interviewed. Staff acknowledged the 1st floor restroom was locked and inaccessible to residents in order to "prevent injury". Staff interviews revealed that in early July 2025 Executive Director and medication technicians ordered housekeepers to keep the 1st floor restroom locked because a resident fell twice in the 1st floor restroom. Staff said that previous to the restroom closure directive, the restroom was only closed during maintenance or cleaning. It was established that residents who were able to to to the restroom on their own may be given access to the public restroom, and those that required incontinence assistance were to be escorted by staff to their room bathroom. According to interviews, there were several residents that had incontinence accidents because they did not get to their room bathroom in time. Staff interviews revealed that residents and visitors did not have access to the 1st floor public restroom without getting the key from the lobby receptionist. The findings revealed that the day receptionist shift is not 24 hours a day, and once their shift was over, there was no staff at the front to give residents access to the 1st floor public restroom.