Complaint Investigation Report

Due to staff neglect resident developed pneumonia while in care:

Facility did not seek medical attention for resident in a timely manner:

On 02/03/2026, LPA interviewed Administrator (ADM) Ganiyu Ajani. ADM stated on 01/25/2026 morning, R1's family members (FM1, FM2) came to the facility to visit R1. ADM stated R1 was checked temperature on 01/25/2026 morning, and the temperature was 97.8 degree F. ADM stated R1 finished breakfast and shower in the morning on 01/25/2026 before FM1 and FM2 arrived at the facility. ADM stated R1's families found R1 was weak and sleepy during their visit. ADM stated he/she explained to R1's families that R1 does not sleep whole night, and kept waking up and walking in the facility. ADM stated he/she explained to FM1 and FM2 that facility staff checked R1's temperature and it was 97.8 degree F which is within the normal range. ADM stated FM1 and FM2 discussed R1's condition on the phone with R1's another family member (FM3). ADM stated FM3 asked him/her to send R1 to hospital. ADM stated he/she had two facility staff sent R1 to hospital on 01/25/2026 around noon time and FM1 and FM2 met R1 at the hospital.

LPA interviewed staff S1. S1 stated on 01/25/2026, FM1 and FM2 visited R1. FM1 and FM2 found R1 was weak, sleepy, and was breathing wheezily. S1 stated he/she took R1's temperature on 01/25/2026 morning and it was 97.8 degree F which is within normal range. S1 stated R1 usually does not sleep whole night and always wakes up during the night. S1 stated R1 is always sleepy at day time. S1 stated R1's families requested to send R1 to hospital. S1 stated two facility staff sent R1 to hospital on 01/25/2026 at noon time.

LPA interviewed staff S2. S2 stated on 01/25/2026, he/she came to work before 12:00PM. S2 stated R1's families requested to send R1 to hospital. S2 stated he/she asked R1's family why and R1's families stated R1 was weak and sleepy. S2 stated he/she explained to R1's families that R1 does not sleep much at night and is always sleepy in the morning. S2 stated R1's families insisted to send R1 to hospital. S2 stated he/she and another staff sent R1 to hospital on 01/25/2026 around noon time..

On 03/26/2026, LPA interviewed FM1. FM1 stated on 01/25/2026 morning, FM2 asked him/her to go with FM2 to visit R1. FM1 stated he/she found R1 was very weak and sleepy which was much different with R1's usual. FM1 stated he/she gave R1's favorite food but R1 did not want it. FM1 stated he/she gave R1 a cup of water, and R1 vomited out. FM1 stated R1 was unable to stand up on 01/25/2026 morning and he/she had to put R1 to rest on bed. FM1 stated R1 was breathing with wheeze.