Complaint Investigation Report

On 12/16/2020, between 11:00 a.m. and 11:45 a.m., LPA Miller conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. LPA conducted an interview and physical plant tour via video chat with facility administrator Judith Muro. LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required.

During LPA Camara’s visit to the facility on 03/04/2022 between 9:47 a.m. and 11:47 a.m., LPA interviewed the administrator at 9:47 a.m., staff 1 at 10:42 a.m. and staff 2 at 10:46 a.m. LPA obtained pertinent documents and conducted a brief facility tour at 11:18 a.m. LPA also conducted a telephonic interview with staff 3 at 3:33 p.m.

During LPA Camara’s visit to the facility on 03/11/2022 between 11:35 a.m. and 12:28 p.m., LPA interviewed staff 4 at 11:07 a.m. and staff 5 at 12:15 p.m. as well as obtained more documents. LPA also conducted a collateral visit with R1’s physician on 03/11/2022 between 1:00 p.m. and 2:18 p.m.

The administrator and staff stated that other than going to the dining room for meals, R1 stayed inside their single occupancy room. R1’s room was equipped with a television which R1 enjoyed watching and R1’s family sent care packages of snack foods which R1 also enjoyed. R1 was friendly but did not have any close friends at the facility. R1 only had one family member who would occasionally visit. R1 did not require assistance with activities of daily living. R1 did receive medication management. Staff stated that since R1 was mostly independent, when they would check on R1 they would knock on the door for permission to enter R1’s room.

Staff stated R1 was last seen at approximately 5:00 p.m. on 12/09/2020, watching television in R1’s room. R1 said goodbye to the staff who checked in as they were leaving for the day. Staff observed R1 was lying in bed watching television; R1 had no complaints. Other staff indicated R1 never complained about not feeling well or anything else; R1 was a very pleasant person. On 12/10/2020, at approximately 08:00 a.m. staff were concerned because R1 had not come to the dining room for breakfast which was very unusual. Staff knocked on R1’s door and when there was no answer, they used a key to unlock R1’s door. It appeared R1 had been sitting on the side of the bed as R1 was found fully clothed and laying across the bed, deceased.

Information gathered reflected R1 was initially admitted to the facility on 08/28/2017 from another assisted living facility. R1’s physician’s report used for admission was from a physician in Hudson, New York dated