Complaint Investigation Report

The investigation revealed the following: Regarding allegation Staff are not honoring resident privacy during resident council meetings. It is alleged staff member assigned to take notes during the Residents' Council Meeting was providing names of residents filing issues/problems with the administration. Interviews conducted with residents revealed, 2 out of 6 residents interview stated to have been or are involved in the resident council meeting and the only staff present is the activity director, who has been invited to assist with taking minutes for the residents. 2 out of 6 residents are aware there is a resident council meeting but do not participate in it and have not heard of privacy/confidentially not being provided during the meetings. 1 out of 6 residents did not know much about the resident council meeting. Interview with Executive Director revealed activity director types the notes taken during the meetings and provides the information of repairs needed in order for the facility to address them without identifying the residents. Interviews with staff revealed 2 out of 3 staff stated not to be a part of the council meeting and 1 out of 3 staff stated to have been assisting with the council meeting since July 2022, takes notes and types the minutes. Documents reviewed revealed Resident Council Meeting Minutes for January 2022 - June 2022 have notes of topics discuss in each meeting with suggestions from residents and a response from each department which is shared with the residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

Regarding allegation: Staff did not assist resident with medical treatment after resident informed staff of falling. It is alleged resident #1(R1) had taken a serious fall outside the facility and R1 had to call 911 her/himself to get any help. Interviews with residents revealed 3 out of 6 residents interview stated to have received assistance when medical care has been needed and emergency medical technicians (EMTs) were contacted to transport residents to the hospital when needed. 2 out of 6 residents stated to have not required medical assistance and/or had fall but are aware they will obtain assistance if necessary. Interview with R1 revealed that on 6/28/22 R1 had fallen around 3:00am in the morning outside the facility. R1 returned inside the facility on their own. Upon staff assisting R1, staff asked R1 if they should call 911 to which R1 responded to staff, "not to see a need to call". R1 change her/his mind and choose to call 911 on their own. Interview with executive director revealed it is facility's policy to contact 911 if a resident sustains a head injury and night staff stated R1 stated to have fallen on her knees and pointed at forehead when describing the fall, no injuries were noted by night staff. Interviews with 3 out of 3 staff interview stated it is procedure to call 911 if residents sustained a head injury. During document review it was observed unusual incident report dated: 7/1/22 notes R1 fell outside the facility approximately at 3:00am. (CONTINUED ON LIC 9099C)