Complaint Investigation Report

There is no indication of dementia or mild cognitive impairment on the medical assessment dated November 29, 2023. Upon admission, it was documented that R1 opted out of providing the facility with an inventory of personal property.

R1’s records obtained at the facility additionally included multiple Physician’s Fax Report of Fall dated January 4, 2024, February 13, 2024, June 11, 2024, January 13, 2025, March 5, 2025, March 6, 2025. In each of those instances, the primary care provider was notified and followed up. Adequate calls to 911 for evaluation and either transportation to a hospital or refusal to pursue such evaluation were systematically documented as well, as confirmed by the charting notes obtained and reviewed.

A Resident Notice to Vacate was provided by R1’s responsible party to the facility on April 5, 2025 informing the facility of R1’s intent to be discharged from the facility effective April 13, 2025. The motive stated on the notice is “ multiple theft of cash and property, right wrist fracture due to employee negligence and involvement in a fall without proper response time ”. R1 was therefore no longer a resident at the facility when the investigation was initiated.

Regarding the allegation that Staff stole residents personal property , the following has been concluded: During the investigation, licensing staff reviewed video footage from a video device installed by R1’s family inside unit #151. Video reviewed shows staff member S1 going into R1’s bedroom closet and removing items. S1 then comes into view of the camera and appears to back away out of view, before proceeding to walk by with items in hand. S1 is later seen leaving R1’s residential unit with items in hand. According to staff interviews, S1 instructed another staff member to tell her later in the shift, in the presence of other staff, to enjoy the items they gave them (even though staff did not give S1 anything). Accomplice staff agreed, later telling S1 that they hopes they enjoys the items and S1 thanked him for the gifts that he gave her. There is enough evidence to support the allegation that S1 stole items from R1’s residential unit.