Complaint Investigation Report

9099C-1...The physician's report notes (R1) also needed assistance with bathing, dressing and toileting and can leave the facility with assistance. The Pre-Appraisal notes (R1) needed help with moving around the facility, toileting and needed special observation/night supervision due to confusion/forgetfulness.

Allegation: Facility staff are obstructing fire exits to prevent residents from leaving. The allegation states staff are putting chairs under the door handles at night to prevent residents from leaving the facility.

The Administrator and caregiver stated that a chair was placed outside of (R1's) room, with (R1's) permission to serve as a reminder for (R1) to call for assistance, when needed, to use the bathroom, or leave their room since it was near a ramp. Both staff stated this idea was approved by (R1's) Physical Therapist, due to (R1) having "mild Dementia- mostly memory issues". LPA viewed (R1's) room and chair that is kept outside the room in the hallway and took photos. LPA observed the top of the chair to be several inches below the door handle on (R1's) room and not be able to prevent the door from being opened. The chair was placed in front of the door, without touching it.

Both staff denied that any other chairs were placed in front of any other doors. LPA did not observe any chairs nearby other doors in the facility. Both staff confirmed that the facility has "on-call" staff who will provide regular incontinent care and answer when residents need assistance.(R1) was unable to be interviewed due to moving from the facility on/around May 18, 2026. LPA was also not able to contact a family member of (R1) after attempting to.

Based on interviews conducted and observations made, the allegation is found to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Facility staff are leaving residents alone at the care home without supervision. The allegation states it was understood that the care home had 24/7 supervision from caregivers; however, the care home does not have care staff at night.

The lead care staff confirmed the Administrator and another staff, who lives at the care home, were filling in when he went on vacation for two weeks. The Administrator stated she was working daily at the facility, including providing nighttime care and supervision, when the lead staff was out of the facility. The lead staff was adamant that staff is present at all times and staff has contacted 9-1-1, on multiple occasions, during the night time shift. *cont on 9099C-2..