Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not prevent resident from entering resident's room

The detail of the complaint alleges staff did not prevent another resident from entering R1’s room.

During the initial and subsequent visits, interviews with Executive Director and staff was conducted on 4/16/25, 4/25/25 and 11/21/25. It was revealed that incident did not occur, as there had been no such incident reported to them. 4 out of 4 staff interviewed denied the allegation stating if a resident entered another resident's room staff would notice and/or it would be captured by hallway cameras. It was also revealed that some residents wander but they are redirected by staff. Of the 5 residents interviewed, 4 out of 5 residents stated they had no issues with anyone coming into their room, nor had they witnessed another resident going into another resident’s room. 1 out of 5 residents was unavailable for interview.

On January 30, 2026, the Department reviewed and the following documents: staff roster/schedule, resident roster, staff training: Understanding Wandering and Elopement and Abuse, Neglect, and Exploitation in the Elder Care setting .

During review of the documents, the Department found that the facility maintains adequate staffing to meet residents’ needs, and the staff are trained in resident behaviors including wandering behaviors.

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.