complaint·August 18, 2023

The investigation revealed the following: Allegation: Facility retaliated against resident for filing a complaint. It is alleged that resident experienced retaliation after filing a complaint through different scenarios that took place thereafter. LPA interviewed 8 residents today and 8 out of 8 residents stated that have not heard of retaliation for filing complaints. Although some feel that some staff could be more kind when dealing with aggressive residents they stated that they haven't experienced retaliation of that sort. LPA's interviews with 6 staff also denied the above allegation and stated that they have not nor have they witnessed another staff retaliate against residents when they file complaints or complain to them personally. The investigation revealed the following: Allegation: Facility staff did not seek medical attention in a timely manner. It is alleged that staff did not seek medical attention in a timely manner for R1 when R1 was found unresponsive by non staff member. It was stated that staff were not "mindful" when asked to call 911. LPA interviewed staff and 5 out of 5 staff stated that when a resident experiences an emergency of that sort, staff will call 911 and a caregiver will stay with resident until paramedics arrive. Staff also stated that rounds are conducted every 2 hours or less depending on the resident needs, some require more frequent checks therefore it may be hourly rounds for those individuals. Interviews with residents, 8 out of 10 residents denied the above allegation and stated that they are given medical attention in a timely manner and see caregivers and staff conducting rounds regularly. The investigation revealed the following: Allegation: Facility staff did not notify resident's authorized representative of a change in resident's condition. It is alleged that R1's responsible party was not contacted when R1 was admitted to the emergency and when responsible party called the staff stated they did not know R1's whereabouts. After file review it was noticed that R1 never had an emergency contact listed and stated responsible party as "self". During interview with S1, staff indicated that R1 never provided an emergency contact and someone did call asking about R1 however, no information could be provided as R1 had not given authorization. S1 stated after this situation they asked R1 if they would like to add an emergency contact but R1 refused. Interviews with residents 8 out of 9 residents denied the above allegation and stated they believe staff will contact responsible party in case of emergencies. Although some residents did confirm they do not have an (Continued on 9099-C) emergency contact listed, therefore, staff would not have anyone to contact. 2 out of the 8 residents that have experienced medical emergencies stated that their responsible parties were contacted with details of their condition. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held with Assistant Administrator Alexander Solorio and a copy of this report was provided.