It is alleged that staff entered R1’s room at night without R1’s invitation or permission which caused R1 to wake up and get startled and distressed when S9 shone a light on R1’s face. Investigation consisted of physical plant tours, interviews with staff, residents, and review of R1 facility file, including admission agreement, physicians report, needs and service plan, and facility staff training. The investigation reveals the following: Interviews with residents revealed that eight (8) out of ten (10) residents stated that residents are not aware of staff entering residents’ rooms without permission. Six (6) out of ten (10) residents stated that staff sometimes wake residents at night to do welfare checks, but residents stated that residents understand the reason for staff doing welfare checks at night. The same six residents stated that no staff have shone a light on their face at night or startled residents at night. Interviews with staff revealed that nine (9) out of nine (9) staff stated not to be aware of staff entering residents’ rooms without permission. Staff always knock on the door or ring the doorbell before entering residents’ rooms and announce themselves. At night, some residents may wake up during welfare checks, but staff try not to startle residents. Eight (8) out of nine (9) staff denied using a flashlight during welfare checks. S9 denied shining a flashlight on R1’s face, and instead, S9 stated that S9 shone the light onto the ceiling. On 11/15/2025, S9 stated that S9 was asked to return the emergency call pendant to R1 at beginning of graveyard shift. Since R1 is an independent resident, S9 does not normally enter R1’s room. S9 stated that S9 was not familiar with R1’s room layout, and therefore, S9 use a flashlight to assist walking into the room. S9 stated that a flashlight is not provided by facility but S9 uses a flashlight because of S9’s poor vision. LPA document review revealed that the facility has provided staff training on proper room entry on 11/17/2025, and 01/05/2026-01/12/2026. S1 stated that facility does not issue flashlights to staff. Based upon the investigation, client and staff interviews, document review, and LPA observations, there is no preponderance evidence to show that staff is entering residents’ rooms without permission and waking up residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held with the Director of Health Services Milca Osorio. A copy of the report was provided.