Complaint Investigation Report

Therefore, since the facility did not intervene in R1's actions (which had proven to be hazardous to others in the facility) other than providing written warnings, the allegation of " Staff failed to provide a safe environment" is SUBSTANTIATED.

Regarding allegation " Lack of care and supervision": LPA Colvin reviewed the facility file for one resident (R2) as well as conducted interviews with staff and residents. LPA Colvin observed that R2 had a significant change in condition from 2019 - 2021, as evidenced by R2's Physician's Reports. In 2019, R2 was ambulatory and able to care for all of their daily needs, but by 2021, R2 was non-ambulatory and needed significant assistance with toileting and bathing. During review of R2's file, LPA Colvin did not observe any updates to the facility's assessment for R2's Care Plan since the quarterly review dated 3/28/20. LPA Colvin did observe an assessment from the Assisted Living Waiver (ALW) Program, though this assessment did not include an evaluation of daily grooming needs. Interviews confirm that R2 originally was very independent, but since R2's return from the hospital in February 2021, R2 needed an increasing amount of assistance.

Additionally, LPA Colvin reviewed the Death Report for R2 from 6/3/21 and observed that the caregivers on duty observed that R2 was non-responsive, but failed to provide aid or contact 911 until after the facility's nurse arrived for their scheduled shift at 6:59am, at which point the staff notified the Nurse, who then instructed them to call 911 while the Nurse provided CPR. It was reported that R2 appeared to have a liquid (possibly soda) in their mouth, which was drained out by the Nurse turning R2 onto their side. R2 was pronounced deceased by the paramedics at 7:38am. It should be noted that R1's Advance Directive stated that R1 wanted full treatment of life saving measures.

Due to staff's failure to document changes in R2's condition and needs, as well as staff's failure to immediately provide life saving measures upon finding R2 unresponsive, the allegation of " Lack of care and supervision" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Kyong "Clara" Suk Lee during the exit interview.