Complaint Investigation Report

A detailed review of the incident report indicated that the staff handled the incident according to regulations. In addition, the client received the appropriate care and supervision before, during, and after the incident. A staff member removed the broken glass and disposed of it accordingly to minimize safety risks. The window was covered by cardboard immediately after the incident. On September 8, 2024, the maintenance staff boarded up the window, and a new window was ordered on September 9, 2024. During a visit conducted on September 26, 2024, LPA observed the broken window that was boarded up securely with thick plywood. The window was boarded using the 5/8 inches thickness of the plywood. Which is the recommended thickness to withstand the impact of debris and strong winds. In addition, the inside windowpane was intact. The expected time of delivery for the window is 2 – 3 weeks which appears reasonable as a special-order item. No deficiencies were observed or cited during the visit on September 26, 2024, the facility was observed to be in good repair with all amenities and safety measures in working order.

The Department has investigated the above-mentioned allegation and based on observations, interviews conducted, and records reviewed there was insufficient evidence to support that the facility was in disrepair. Therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) was provided to LVN Case Manager, Amanda Thomas at the conclusion of the visit.