complaint·October 22, 2024

It was alleged that resident is not accorded dignity in their personal relationships with staff. On 08/01/2024, the Department received two (2) self-reported incident reports regarding two (2) staff members who no longer work at the facility as they were suspended on 07/31/2024. The incident reports stated that on 07/06/2024, two staff members were assisting a resident when Staff #1 (S1) slapped the resident. Staff #2 (S2) witnessed the incident and recognized it as abuse, but informed the Administrators later on 07/31/2024 due to fears of retaliation from S1 and Staff #3 (S3), the relative of S1. The Department received the SOC341 for this incident on 08/02/2024. The second incident report stated that on 07/12/2024 and 07/22/2024, S3 was verbally abusive to Resident #1 (R1). On 07/12/2024, R1 asked S3 for a cleaning. R1 requires a two (2) person assist and said they did not feel comfortable with S3 performing the cleaning solo, however, S3 was insistent. R1 refused the cleaning due to S3’s verbal abuse during the exchange and the potential dangers of the solo clean. On 07/22/2024 after changing the sheets on R1’s bed, R1 asked S1 and S3 to shift the bed. S1 and S3 began trying to shift the bed without unlocking the wheels and when R1 stated that the wheels need to be unlocked, S1 raised their fists at R1 asking if the resident wanted to fight them, and both S1 and S3 became verbally abusive. LPAs Barutyan and Chochian as well as Brian Balisi and Trevor Byrne conducted separate case management visits for the incidents on 08/02/2024. The Administrators stated that they were not aware of how S1 and S3 were treating the residents as S2 and S4 were afraid to report the abuse. LPA interviewed R1 on 08/02/2024 who stated that they felt “unsafe” and that the staff had a “hostile” relationship with R1. LPA interviewed R1 on 08/14/2024 who stated that they have “not experienced any mistreatment since the two staff left” and that they are “treated well here compared to other places [they have] stayed at and heard about.” LPA interviewed S4 on 08/02/2024 who stated that they have “had to tell [S3] to ‘calm down’ many times when [S3] is handling [R1] because [S3] gets verbally aggressive” and that S1 and S3 have both said that they "wish the residents were dead." LPA was unable to interview S2 as they are taking a leave of absence for personal reasons. Based on incident reports submitted to the Department and interviews conducted, the allegation “resident is not accorded dignity in their personal relationships with staff” is deemed SUBSTANTIATED at this time. While the allegation is substantiated, a deficiency will not be cited as the facility was issued a deficiency today, 10/22/2024, for a similar allegation of an unrelated complaint the Department received on 08/02/2024. Exit interview conducted. Appeal rights and a copy of the report was provided. It was alleged that staff does not ensure that residents are provided activities. LPAs Barutyan and Chochian observed board games and coloring available for residents during the initial visit on 08/14/2024. LPAs observed two (2) residents playing Connect 4 with staff on an unrelated visit conducted on 08/02/2024. Interviews conducted explained that two (2) residents are unable to communicate, and the other two (2) residents prefer solitary activities. Administrator Havsgaard stated that accommodations are made for the two (2) residents who do not wish to partake in socialization activities. The Administrators have an informal movie club with Resident #1 (R1) in which they ask R1 for movie recommendations and then have discussions about the movie with R1. R1 also stated they do not want to play games with other residents and instead, prefers to read or watch TV in their room. The Administrators and staff stated that Resident #2 (R2) also does not want to play games, so they encourage socialization by creating an office-like setting and referring to R2 as their “boss.” Administrator Havsgaard also stated that they invited a neighbor over to play chess with R2. R2 and responsible party of R2 confirmed that the administrators threw a birthday party for R2. Record review of the activity schedule indicated that there are planned activities for residents. Administrators confirmed that the activities do not always happen as per schedule as residents decline the activities occasionally. Based on interviews, observation, and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “staff does not ensure that residents are provided activities while in care” is deemed UNSUBSTANTIATED at this time. It was alleged that staff does not allow resident to go on outings. Record review of R2’s physician’s report documented that R2 is unable to leave the facility unassisted. Interviews conducted with the administrators, R2, and R2’s responsible party revealed that R2 goes on outings but is accompanied by the Administrators. R2 stated that the Administrators take him/her to R2’s responsible party’s house and other outings when requested. R2 had no complaints about the frequency of outings. R2 and Administrators confirmed that Ubers are ordered for R2 and someone will accompany R2 on the car rides. Interview with R2’s responsible party confirmed that R2 is able to visit at their house and stated that “Vanessa assists [R2] on outings.” Based on record review and interviews, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “staff does not allow resident to go on outings” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC-9099C. It was alleged that licensee is financially abusing a resident in care. LPA spoke with R2 who stated that they used to be an accountant, are in charge of their finances, and that they “have friends who also help sometimes but for the most part, it's just [themselves].” LPA interviewed R2’s responsible party who stated that R2 “manages their finances and [R2] has privacy to do so.” Responsible party stated they “have no concerns of financial abuse.” Record review of R2’s physician’s report, dated 10/11/2024, documents that R2 is “able to manage own cash resources.” Administrators stated that the office area for R2 is not monitored and that R2 manages their finances on their own personal computer that others do not and cannot access. LPA Barutyan observed R2 using their computer without monitoring on 08/14/2024 and 08/02/2024. The complainant alleged that the surveillance camera in the office common area is angled to point at R2’s computer and monitor potential financial information. LPA observed a camera in the corner of the office common area that was not pointing at R2’s computer and was instead, pointing to the front of R2. During the visit, the cameras were found to contain an auditory component and the Administrators immediately removed the cameras. However, because the camera was not positioned in a way to capture information on R2’s computer, there is not enough evidence to suggest that financial abuse could have occurred. Based on observation and interviews, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Licensee is financially abusing resident in care” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC-9099C. It was alleged that the licensee does not ensure that residents are provided with quality food while in care. On 08/14/2024 LPAs Barutyan and Chochian inspected the kitchen and observed a sufficient supply of perishable and non-perishable foods. LPAs observed a variety of food groups and food that was of good quality. Interviews with staff and residents noted that staff ask R1 what they’d like to eat and R1 buys their own food and has them labeled separately. Staff #4 (S4) stated that R2 usually requests chicken teriyaki or salmon. S4 stated that they “sometimes make mac and cheese as it is easier for the other residents to eat” and that they “always make vegetables with the meals.” S4 makes broccoli with parmesan cheese and half a bagel with cream cheese for R1 because R1 requests them with the food R1 buys for self. The facility also has specific groceries for R1 because R1 is selective of their foods (ie. specific cereals, brands) and those groceries are marked that they are for R1. Family of Resident #3 (R3) deliver lunch/dinner every day as R3 prefers their cultural foods. LPA Barutyan interviewed family of R3 and found that they have agreement with the facility to provide the lunch/dinner for R3, per family’s request. LPA reviewed a signed agreement documenting the food accommodations for R3. Family of R3 stated that the facility provides simple breakfast like oatmeal, fruits, salad and will give dinner alternatives like mac and cheese if R3 does not want the lunch/dinner that was delivered by them. LPA also reviewed records and observed a signed meal agreement between the facility and the family of R3 indicating that the family will provide R3’s meals. S4 stated that sometimes R3 does not eat the food provided by family, so S4 makes soft foods like mac and cheese and mashed potatoes and then serves the leftover dinner at a later time. LPA Barutyan interviewed R1 on 08/14/2024 who stated that they “have [their] own special diet and buy [their] own food, but staff accommodate requests when [they] ask for food.” LPA also interviewed R2 who stated that the “food is good with a good variety” and that “staff ask what food [they’d] like to eat that day.” LPA observed S4 asking R2 on 08/14/2024 what they would like for dinner during the visit. LPA interviewed responsible party of R2 who stated that they have not been at the facility during food service “but knows that [R2] gets to choose their food” and that R2 “has not had any complaints.” LPA interviewed responsible party of R1 who stated that they “do not know much about the food as [R1] buys [their] own food” and stated that they usually see breakfasts, like scrambled eggs, served to other residents when they visit R1 in the mornings. Based on observation, interviews, and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “licensee does not ensure that residents are provided with quality food while in care” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.