Complaint Investigation Report

1) Allegation Staff did not provide a resident access to a walking device. It is alleged that the facility took away R1 cane and provided R1 with a walker and that the facility did not provide R1 with instructions for use. LPA interviewed six (6) staff and six (6) of (6) staff denied the allegation. S6 stated that the safety of the residents is the facility primary responsibility, and that R1 was combative and a strap on R1 cane was tearing R1 skin. R1 was provided with a walker to prevent R1 from striking other residents with the cane and to assist her in ambulating. The facility did not provide physical therapy to R1, on how to use the walker because it was not ordered by physician or required according to staff assessment completed by staff. One staff member stated that R1 was able to use walker just fine and that R1 was eventually given cane back when facility was sure R1 would not strike other residents. LPAs interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. Five (5) of (5) residents stated that the facility has never taken away their canes or walkers. There is insufficient evidence to support this allegation.

2) Allegation: Staff authorized change in a resident's medical needs without proper consent. It is alleged that facility pressured resident’s family members into giving anti-psychotic to resident. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegations. R1 was admitted on 07/20/2024 and moved out on 08/18/2024. According to S3, R1 was prescribed an anti-psychotic for aggression and being combative on 08/15/2025. S3 stated S3 never personally administered the anti-psychotic due to her schedule. S1 stated physician is always consulted first and that the family/responsible party along with resident’s physician make the final decision for any new medication(s). Record reviewed showed that R1 physician ordered the anti-psychotic, and family/responsible party agreed, for agitation with start date of 08/16/2024. There is no evidence that family was pressured into authorizing anti-psychotic for resident.

3) Allegation : Facility staff do not intervene when resident's engage in physical altercations. It is alleged that R1 had an altercation with another resident and the staff did not intervene. LPA interviewed six (6) staff, and all six (6) staff denied the allegation. No staff witness any altercation between residents. One staff stated resident was found on floor by staff on duty and SIR submitted to the department. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. All five (5) residents stated they have never witnessed resident on resident violence at facility. There is not enough evidence to show that staff allowed aggressive behavior between residents.