Complaint Investigation Report

of blood and bleeding from the head on 12/07/22 at the facility. It was unclear how long R1 was laying on the floor.

· 02/27/23: Interview with the facility administrator, Jonathan Perles confirmed R1’s admission in 2015, and acknowledges R1’s fall on 12/07/23. Interview with R2 confirms R1’s fall, but R2 could not recall much details of the incident. Interviews with Staff 1 (S1) and Staff 2 (S2) confirm R1s fall on 12/07/23, at approximately 3:00am, confirms the presence of blood to the forehead of R1, confirms cleansing and a band aid only applied, confirms that R1 was not sent to the hospital until 4:00pm on 12/07/23. Interviews with staff also confirmed that R1’s responsible person(s) was not notified of R1’s fall, but only of the hospitalization.

Although Staff was made aware of R1’s fall at approximately 3:00am in morning of 12/07/22, and only basic first aid was applied, staff did not seek the medical attention for R1 until 4:00pm that afternoon. Furthermore, a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of and acknowledged that R1’s cognitive and physical condition had progressed, continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. Therefore, based on the information obtained, the allegation is Substantiated. Citation(s) issued on the 9099D.

Exit interview conducted. A copy of this report and appeal rights issued.