Complaint·September 29, 2023

This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023. The investigation revealed the following: Allegation: Staff did not intervene in resident-on-resident altercations. It is alleged that a resident was walking to lunch and another resident hit them in the head. LPA interviewed staff S1– S10, and 10 out of 10 stated that no resident had reported that they were physically attacked by another resident. LPA interviewed residents R1 – R10, and 9 out of 10 stated that they had never been attacked by another resident. Based on interviews there is insufficient evidence to support the allegation: "Staff did not intervene in resident-on-resident altercations." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not ensure that resident received medical attention while in care It is alleged that a resident was shoved by another resident and their shoulder was injured to the point of needing an injection for pain. LPA interviewed staff S1 – S10, and 9 out of 10 of those interviewed stated that no residents reported that they were physically attacked by other residents. S1 added that at least one resident reported to them that they were attacked by a homeless male while out walking with a friend. LPA interviewed R1 – R10, and 9 out of 10 residents denied that anyone has hit or attacked them there. R1 stated that they told S5 and S1 that they were physically attacked. S1 called the police regarding the incident but no official report was taken and no injury was noted per S1. S1 also added that no LIC 624 form was completed and submitted to Licensing at the time. During LPA's interview with S10, LPA interviewed S10 who stated that R1 complained of chest and shoulder pain. R1 was evaluated by facility nurse and R1 was referred to Valley Internal Medicine where the resident was evaluated. LPA interviewed W1 regarding alleged altercation and both R1 and W1 stories coincided with each others account of what happened. Cont'd on 9099-C This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 9/29/2023. Based on interviews there is insufficient evidence to support the allegation: "Staff did not intervene in resident-on-resident altercations." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Administrator Assistant, Stephanie Brynjolfson and a copy of the report was provided.