Complaint Investigation Report

Additional witness interviews were conducted during the investigation.

Regarding the allegation that Facility failed to ensure oxygen tanks were in working order , the following has been concluded: Witness and resident interviews conducted evidenced that the equipment used by R1 for supplemental oxygen was functioning correctly. However, due to poor vision documented in R1's assessment and evidenced in interviews, R1 would occasionally require staff assistance to operate her small oxygen tank, with occasional excessive waiting times. Issues with oxygen seem to have been solved by the provision of a concentrator.

Based on the evidence gathered, the allegation is found to be Unsubstantiated, meaning that 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.

An exit interview was conducted and a copy of this report was provided to facility representative.