Complaint Investigation Report

there's no incident that the staffs at the facility did not ensure that the the facility grounds/backyard/ courtyard are free from hazards. LPA Brown unable to interview three (3) residents as Resident #1 (R1) passed away on 12/29/2023, and Resident #7 (R7) and Resident #9 (R) were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they all ensure that the facility grounds/backyard/courtyard are free from hazards to residents. Interviews with nine (9) of nine (9) staffs revealed that no incident happened at the facility that they did not make sure that the facility grounds/backyard and courtyard are free from hazards. Six (6) of six (6) staffs interviewed stated that no incident happened at the facility that they did not ensure that the facility grounds/ backyard/courtyard are free from hazards to R1. Moreover, all staff interviewed reported that the facility grounds/backyard/courtyard were always maintained clean. During the facility visit on 11/30/2023 and 07/30/2024, LPA Brown observed the facility grounds/backyard/courtyard are free from hazards to residents and no potholes observed.

The second allegation indicates that Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care. Interviews with seven (7) of seven residents indicated that staffs at the facility are checking on them multiple times in a day. Seven (7) of seven (7) residents interviewed reported that staffs at the facility always checks on them and there's no incident that staffs at the facility did not check on them. LPA Brown unable to interview three (3) residents as R1 passed away on 12/29/2023, and R7 and R9 were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they are checking on their residents every two (2) hours, more frequent if needed. Interviews with five (5) of six (6) staffs indicated that on 09/08/2023, staffs at the facility adequately supervise R1 and they all reported that R1 has a habit of arriving late at the facility after a night out with friends as during that time, R1 has his own vehicle which R1 parks at the facility back alley way. Interview with Staff #8 (S8) indicated that S8 was working at the facility on 09/08/2023 and S8 was informed by a skilled nursing staff that a resident was at the back alley of the facility and they both approached the resident observed and S8 stated that it was R1 that was at the back alley of the facility at around 12:00 AM. Moreover, S8 stated that S8 checked on R1 and R1 said that R1 wants to stay at the back alley and refused to go back to R1's room. S8 added that S8 checked back on R1 at around 01:30 AM and saw R1 fell from R1's motorized wheelchair and S8 immediately attended to R1 and S8 contacted Staff #9 (S9) for assistance to help R1 back on R1's motorized wheelchair. S8 stated that they observed bruises on R1 and informed R1 that they have to checked R1's bruises but R1 refused with aggressive and combative behavior and that's when S9 called the paramedics for R1. Interview with S9 indicated that S9 was working at the facility on 09/08/2023 and S9 reported that S9 assisted S8 to transfer R1 back on R1's motorized wheelchair and they both observed bruises on R1 and informed R1 that they have to checked R1's bruises but R1 refused with aggressive and combative behavior. Interviews with S8 and S9 revealed that due to R1's observed bruises, *Continuation in LIC9099C***