Complaint Investigation Report

Staff allowed resident in care to leave the facility unassisted.

It is alleged that due to facility staff neglect Resident #1 (R1) eloped the facility unassisted. To investigate this allegation LPA reviewed R1's Physician report and was revealed that R1 cannot leave the facility unassisted or unsupervised. Furthermore, LPA conducted an interview with Administrator and S2 and both confirmed that R1 eloped the facility without staff knowledge on 07/05/2025 at around 8:30 AM. Therefore, based on the record review and information gathered through interviews this allegation is deemed Substantiated.

Staff did not provide medication assistance to resident in care.

It is alleged that the facility staff does not provide R1's medication properly. To investigate this allegation LPA conducted an interview with the Administrator who denied the allegation and informed LPA that they always provide medication to all the residents in a timely manner without any discrepancy. However, review of R1's medication revealed that the facility was supposed to start R1's prescribed medication Fluoxetine HCL (mental health condition medication) on 06/27/2025. LPA counted R1's medication and it was discovered that five (5) pills were missing from the Fluoxetine HCL bottle. Additionally, LPA reviewed other four (4) prescribed medication of R1's and they were observed to have discrepancies as well. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. Therefore, based on the medication record review, interviews, and observation this allegation is deemed Substantiated.

Staff cannot properly communicate with residents in care.

It was alleged that the facility staff do not speak English and is hard to communicate with residents in care. To investigate this allegation LPA conducted an interview with the Administrator who admitted that S1 does not speak English; however, uses an application through their personal cellular telephone to communicate with the residents in care for their basic needs. Furthermore, LPA conducted an interview and concluded that one (1) out of one (1) staff was not able to communicate in English with the residents of which the majority speak English. Moreover, interviews with three (3) out of five (5) residents confirmed that they have trouble communicating with staff for their basic needs. Lastly, during todays visit LPA used Focus Language International Inc Telephone-Based Interpreter service to conduct an interview with S1 due to language barrier. Based on interviews and LPA's observation this allegation is deemed Substantiated.

Deficiencies issued and appeal rights explained and given. Exit interview conducted and copy of this report signed and delivered.