Complaint Investigation Report

On 05/29/24, LPA Rios interviewed a Registered Nurse (RN) who is part of the Assisted Living Waiver Program (ALW) team, familiar with R1's placement. On 08/27/24 LPA interviewed R1's assigned Public Guardian (PG) at the time.

A review of R1's record shows R1 was admitted to this facility on 09/24/21. According to the interview with R1’s PG they confirmed R1 has had periods where they have been admitted to skilled nursing facilities, hospitals and rehabilitation centers due to R1’s behavior at this facility. PG’s interview revealed the facility has always held a bed for R1 while waiting for R1’s discharge during those periods. On 06/12/24, the facility provided to the Community Care Licensing Department (CCLD) information regarding their efforts to transfer R1 to another facility. According to the information provided on January 2024 the administrator notified ALW nurse of R1’s change in behavior and requested assistance with finding another placement that could provide the required level of care. On 03/18/24 the administrator contacted R1’s PG notifying that the resident required a higher level of care and needed to be transferred. The interview with PG on 08/27/24, confirms they received a request on 03/18/24 for a transfer and they completed and returned the requested document. On 05/16/24 facility administrator coordinated an assessment with another facility, but the assessment resulted in a failed admission.

Interviews with two (2) staff and the administrator on 05/29/24, revealed R1 will wander into other resident’s bedrooms and have heard other residents complain about R1’s behavior entering rooms without permission. Staff have also heard residents complain about R1’s yelling in the hallways repeating the same statements. Interview with nine (9) out of thirteen (13) residents who were interviewed for this allegation also corroborate witnessing R1 wander into their rooms or other rooms and yelling in the hallways. Interview with administrator revealed R1 has been known to display these behaviors when they need a medication adjustment. LPA attempted to interview R1, but R1 did not respond to questioning. One (1) staff revealed they witnessed a resident #2 (R2) push R1 causing R1 to fall down to the floor. Staff explained that R1 was grabbing R2’s plate. Another staff witnessed the same resident R2 grab R1 and return R1 to R1’s room. Staff and residents interviewed also reported seeing R1 with a bruise on their face recently prior to LPA's visit. LPA's observation of R1's face on 05/29/24 did not reveal a bruise. Staff and administrator interviewed report not witnessing how R1 got a bruise but that it could have been an un-witnessed fall. (Page 2 of 3)