Complaint Investigation Report

On 04/10/2024, from 9:35am to 11:00am, Licensing Program Analysts (LPAs) Rachael De Leon and Melisa Rankin conducted the 10-day complaint visit to the facility. LPAs De Leon and Rankin met with the Administrator and explained the purpose of the visit. The LPAs requested records pertinent to the investigation. LPA De Leon requested video footage for the dates of 03/29/2024 through 03/30/2024 for the camera located in the common area hallway and living room. The Administrator was informed the complaint was assigned to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and that the investigator would return at a later date to complete the investigation.

On 04/23/2024, from approximately 12:05pm to 1:17pm, the Department’s Investigators Bendana and Miles conducted interviews with the Licensee, Staff #3 (S3), and the Administrator; on 06/05/2024, at approximately 12:36pm, Investigator Bendana conducted an interview with R1’s resident representative; on 06/19/2024, at approximately 11:24am, Investigators Bendana and Miles attempted to interview R1, who was unable to be interviewed due to their dementia; on 08/22/2024, from approximately 12:28pm to 12:54pm, Investigator Bendana interviewed R1’s Primary Care Physician (PCP), and Witness #1 (W1). Staff #1 (S1) and Staff #2 (S2) were unable to be interviewed due to moving out of the country.

In addition, the investigator reviewed Marian Regional Medical Center records, Wilshire Home Health records, RING camera video footage, photos of sensor and alert system of R1’s bedroom, and other facility file documents related to the investigation.

According to the facility file documents reviewed R1 was admitted to the facility on 02/17/2020. The Preplacement Appraisal Information, dated 02/17/2020, listed R1 needed to use a cane or four-wheel walker with seats and brakes.