Complaint Investigation Report

Regarding the allegation that Staff violated resident's personal rights , the following has been concluded: Based on records and evidence reviewed, observation conducted at the facility and interviews conducted, it is determined that on multiple occasions, facility staff passively or actively disregarded the resident's expressed wishes and either continued providing care without taking the request into account or acknowledging it. Resident R1's physician report on file along with multiple appraisals indicate that R1 does not have dementia and is able to express their needs and wishes, which were then ignored by facility staff. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D.

Regarding the allegation that Staff isolated resident while in care , the following has been concluded: Based on interviews conducted and evidence reviewed, it was confirmed that on multiple instances, facility staff locked the door to R1's unit in the evening despite requests made verbally to leave the door unlocked. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D.

Regarding the allegation that Facility is in disrepair , the following has been concluded: Based on facility visit and interviews conducted, it was determined that following a technical incident, the facility's call system was left non-operational during an entire week-end, with no alternative means of contacting staff to request assistance or care being provided. At the time of the initial visit, visual alerts were observed to be operating, but sound alerts and doorbell rings were still not working. Therefore the allegation is Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D.

Regarding the allegation that Facility is unsanitary , the following has been concluded: Based on evidence submitted and interviews conducted, facility staff was noted to not be observing basic infection prevention measures and were confirmed to be handling food or drinks with the same gloves that they had conducted toileting and handling of incontinence items with, thus not meeting the standards of sanitation required by Title 22 regulations. The allegation is thus found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.