Complaint Investigation Report

During the initial visit on 08/25/2025, between 2:25 p.m. and 3:50 p.m., LPA Arroyo conducted a physical plant tour with the Licensed Vocational Nurse (LVN) and requested and obtained copies of pertinent documents. On 10/14/2025, between 10:10 a.m. and 2:42 p.m., LPA Arroyo interviewed five staff and six residents. On 01/07/2026, between 09:45 a.m. and 1:30 p.m., LPA Arroyo observed residents in the common areas, conducted interviews with five staff members, conducted a resident file review, and obtained copies of pertinent documents. Additionally, during the course of the investigation, interviews with resident family members were conducted and police report was obtained.

Records reviewed and interviews conducted revealed that R1 was admitted to the facility on 06/27/2023. According to R1’s physician’s report dated 02/26/2025, the primary diagnoses include Mild Cognitive Impairment (MCI), hypertension, and hyperlipidemia, with a secondary diagnosis of Chronic Kidney Disease stage 4 (CKD IV). The report indicated that R1 was not confused or disoriented and did not exhibit inappropriate, aggressive, wandering, or sundowning behaviors. It noted that R1 was able to follow instructions and communicate their needs. The report also described R1 as non-ambulatory and able to bathe, dress/groom, feed, and manage their own toileting needs. Additionally, R2 was admitted to the facility on 05/25/2023. Per the physician’s report dated 06/11/2024, R2 was also able to follow instructions and communicate their needs. R2’s primary diagnoses include dementia, Congestive Heart Failure (CHF), hypertension, Chronic Obstructive Pulmonary Disease (COPD), and depression. The report indicated that R2 was occasionally confused or disoriented and occasionally exhibited inappropriate, aggressive, wandering, or sundowning behaviors. It also described R2 as non-ambulatory and requiring assistance with Activities of Daily Living (ADLs), including bathing, dressing/grooming, feeding, and toileting.

The investigation revealed that on 08/23/2025, R1 was sent to the hospital at the request of R1’s family. Although interviews indicated that R1 may have been experiencing bleeding, family members reported that R1 was taken to the hospital due to stomach problems which included pain and diarrhea.