Complaint Investigation Report

CW denied witnessing S1 breaking R1’s arm, nor did they witness any staff member having a physical altercation with any resident in care. CW did not know the last name of S1. LPA’s subsequent interview with CW did not reveal any additional information about injuries caused by S1 to any residents in care. LPA’s records review revealed that R1 passed away on November 21, 2022. LPA conducted an interview with business office manager (BOM), who stated that S1 was never employed by the facility, past or present. LPA’s records review confirmed BOM’s statement regarding S1. LPA conducted interviews with five (5) staff members, all of whom denied knowing S1 as their coworker. LPA conducted interviews with 14 residents, none of whom experienced rough handling or physical altercation by staff. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated.

It was alleged that facility did not report unusual incident to CCL. The complaint report did not contain any relevant information. LPA conducted an interview with a confidential witness (CW) for additional information, but CW did not provide any relevant information. LPA conducted interviews with six (6) staff members, all of whom stated that any unusual incidents are reported to medication technicians who then report to the management. The management then reports to the Department and keeps the incident reports for their record keeping. LPA observed past incident reports provided by business office manager (BOM) and confirmed the statements from the staff members interviewed. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated.

It was alleged that facility does not have enough food for residents’ daily nutritious needs resulting in weight loss. Information received indicated that the facility regularly runs out of food, and residents are losing weight due to missed meals. LPA conducted five (5) unannounced tours of the facility within a span of 7 days and observed that the facility had sufficient supplies of food for residents in care. LPA conducted interviews with 14 residents, none of whom experienced missing any of the three (3) daily meals. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA conducted interviews with six (6) staff members, all of whom denied the facility running out of food for residents. One (1) of the six (6) staff members interviewed stated that they have never witnessed the facility running out of food in the past 14 years. The evidence found during the investigation did not meet the preponderance of evidence standard therefore, this allegation is unsubstantiated.