Complaint Investigation Report

**Allegation #1:** Staff are not notifying the residents' representatives of unusual incidents.

Staff 1-2 (S1-S2) and residents 1-6 (R1-R6) interviewed stated that the facility staff do notify residents' families and representatives of unusual incidents. S1-S2 reported that R1's family was notified when R1 fell while going outside to smoke a cigarette and was subsequently taken to the hospital. S1-S2 also stated that R1's family was immediately informed when R1 fell and tested positive for COVID-19, leading to R1 being quarantined for 10 days. S1-S2 mentioned that R1 does not have a medical or financial Power of Attorney (POA) representative. Both S1-S2 and R1-R6 denied the allegation.

**Allegation #2:** Staff would not allow the resident to have a telephone call.

Staff 1-2 (S1-S2) and residents 1-6 (R1-R6) interviewed stated that staff do allow residents to have telephone calls. S1-S2 noted that R1 has a personal cellphone and can make and receive calls freely. S1-S2 confirmed that residents are permitted to receive telephone calls and that R1 can talk to her family at any time. Despite R1 being quarantined for 10 days due to a positive COVID-19 test, and the facility being shut down by the Public Health Department during a COVID-19 outbreak, S1-S2 clarified that this did not prevent R1 from receiving and making telephone calls. Both S1-S2 and R1-R6 denied the allegation.

**Allegation #3:** Staff mismanaged residents' vitamins.

Staff 1-2 (S1-S2) and residents 1-6 (R1-R6) reported that the staff do not mismanage residents' medications. S1-S2 and R1-R6 indicated that staff dispense medications according to the physicians' orders. S1-S2 specified that R1 is prescribed vitamin B-1 100 MG tablets, not B12, as per R1's doctor's orders. R1 takes one B-1 tablet orally once daily. S1-S2 affirmed that R1 does not take B12 vitamins. Both S1-S2 and R1-R6 denied the allegation.

The investigation consisted of the following: In response to the COVID-19 pandemic outbreak, the Public Health Department mandated the temporary closure of the facility, prohibiting visitor access until clearance was obtained from the department. Staff members S1-S2 confirmed that during this period, all necessary medications for Resident 1 (R1) were administered in accordance with medical directives.