Complaint Investigation Report

Information obtained from interview with Administrator stated that it would be impossible for Staff#2 to block Resident#1 with the refrigerator door because the refrigerator doors are not long enough to block the access into the living. Information obtained from interview with Staff#2 denied that he would block Resident#1 from exiting out of the kitchen. Staff#2 stated he would tell residents to wait to go down the ramp, in the event the ramp was wet from mopping. Staff#2 also denied telling any resident to lift their walker over a refrigerator door. Staff#2 denied that opening the refrigerator door would block residents from moving around because the refrigerator doors were not long enough to block the residents. Information obtained from interview with Resident#1 stated that Staff#2 did stop Resident#1 from going down the ramp by blocking Resident#1 with the refrigerator door. LPA observed that the refrigerator door was unable to block residents from freely moving from the kitchen down the ramp into the living room.

Regarding the allegation that the staff are not ensuring residents are provided privacy, it was reported that the facility were failing to stop Resident#3 from entering Resident #1’s bedroom. Information obtained from interview with Administrator indicated he was advised of the concerns and purchased a lock for Resident #1’s door on April 13, 2026. Information obtained from additional staff interviews confirmed that there was an issue with Resident #3 entering other residents’ rooms, but the issue was rectified. Interview with residents corroborated the information and stated there were no further concerns.

Regarding the allegation that staff did not safeguard resident’s property and valuables, it was reported that Resident #1’s rosary was broken by a resident. Information obtained from interview with Administrator stated that staff found Resident#1 Rosary necklace on the floor under Resident#1 bed. Information obtained from interviews with staff stated that none of them saw who or how Resident#1 Rosary necklace was broken. Information obtained from Resident#1 stated that he believes Resident#3 wandered into Resident#1 room and broke Resident#1 Rosary necklace. Additional interviews with residents indicated there were no concerns regarding their personal property being safeguarded.

Based on interviews, record reviews, and observations, the allegations that staff do not treat residents with dignity and respect, staff are not ensuring residents are provided privacy, and staff did not safeguard residents’ property and valuables are deemed UNSUBSTANTIATED. A finding that the allegations is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted. A copy of this report was provided to Alexa Cardenas - Caregiver.