Complaint Investigation Report

S2 shared that R1 was walking in the hallway to the activity room and fell due to trapping on R1s shoe. S2 stated R1 was active and did not know he/she was unbalanced in walking. S2 stated R1 always likes to walk by himself/herself. S2 also mentioned R1 had a fall in his/her bedroom. R1 had a bed alarm sounded and staff came to check immediately. S2 stated staff called 911 and R1 was sent to hospital. S2 and S4 stated staff check residents every two hours. S3 also mentioned that they set up a bed alarm for R1 after R1s fall in October 2023 and arranged a staff to sit in the second floor (memory care unit) where they can directly monitor R1s bed alarm and the door of R1s bedroom.

Based on records review, R1 is an ambulatory resident in memory care. On the facility’s evaluation, it was determined under the criteria of mobility that R1 requires stand by assistance into/out of shower for safety reasons.

Regarding the allegations of facility staff handled resident in a rough manner and facility staff forced resident to eat, RP observed that a staff grabbed the resident (R2) by the arm and pulled R2 out of his/her wheelchair and forced R2 to eat.

According to staff interviews, S1 stated he/she does not know R2. S1 stated he/she helps to feed residents in dinner. S1 denied that he/she forced resident to eat or handled resident in rough manner. S1 stated usually only 2 or 3 residents need to be fed. S3 shared that there are 4 caregivers in the dining room during the mealtime and always two caregivers to help feed the residents. S3 stated caregivers try to feed residents in a gentle manner but resident might try to approach to the food by themselves while caregivers try to feed residents in an unstable way. S4 stated he/she never saw staff handling residents in rough manner.

LPA Chiang also interviewed six residents. R3 stated the facility staff are kind to him/her. R3 stated the facility never handled him/her in a rough manner or force to do anything. R4 and R5 stated that they are able to feed themselves. R8 stated he walks to dining room to eat by himself. All residents mentioned that they did not see or hear staff handling residents in a rough manner.