Complaint Investigation Report

“Resident needs are not being met” and “Facility is not ensuring resident’s safety” - Complainants alleged that Resident 1 (R1) needed a higher level of care due to increased agitation and that R1 was not safe at the facility because they weren’t being properly supervised. Complainants stated that R1 would go on walks by themselves and that the facility only had 1 staff member to care for 4 to 5 residents. Review of R1’s Physician’s Report dated 08/25/2023 states that R1 is able to leave the facility unassisted. During visits conducted on 06/06/2024 and 07/03/2024, LPA observed that there were 2 staff members on site. Interviews conducted with R1 and Resident 2 (R2) stated that they were happy at the facility and that they had no concerns about the care being provided at the facility. These allegations are Unsubstantiated .

“Facility is not notifying responsible party of change in condition and/or needed medical care” - Complainants alleged that the responsible party for R2 was not notified when they went to the hospital. Complainants also stated that R1 was prescribed a new medication and that the responsible party was not notified of the medication change. Review of R1’s file indicated that R2 is their responsible party. Interview conducted with R1 and R2 stated that R2 is the responsible party for R1. Review of R2’s file indicated that they are their own responsible party. Requests to the Complainant for additional documentation to verify the responsible parties were unsuccessful. Review of incident reports for R1 indicated that the facility would notify R2 appropriately. Interview conducted with R2 stated that they went to the hospital and was picked up by a family member. These allegations are Unsubstantiated .

“Facility failed to meet mandatory reporting requirements due to lack of staff training” - Complainants stated that facility staff told them that they haven’t received training for mandated reporting or for dementia behaviors such as wandering. Complainants also stated that facility staff did not report that R1 was hitting other residents. Review of staff files indicated that all staff have received training for mandated reporting and for dementia behaviors. Staff interviews conducted indicated that staff are aware of when they need to report incidents related to mandated reporting and for dementia behaviors. Staff interviews conducted provided conflicting statements. 3 of 4 interviews stated that while R1 has been observed to be verbally aggressive towards other residents, they have not seen R1 hit or be physically aggressive towards R2 or other residents in the facility, while 1 of 4 interviews conducted stated that they did not observe R1 hitting R2 or other residents but heard that it was happening. This allegation is Unsubstantiated .