Complaint·March 28, 2024

The details of the complaint alleged that the facility administrator (S1) did not notify R1’s mental health provider about R1’s change in condition between 08/02/2023 and 12/01/2023. On 03/28/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R11) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not notify residents' physician about changes in residents' condition while in care. Staff (S1-S4) stated that they had no knowledge of changes in R1’s condition because R1 never came to the staff and let them know that R1 was having any issues. S2 stated If R1 had come to us and said R1 was in crisis we would have notified R1’s mental health provider, but R1 did not; R1 never had an acute episode in the facility to my knowledge. S2 stated further that R1 had clinical and mental health issues while R1 was staying here but they were not acute; and during this period, he did not report any to the staff. LPA interviewed residents R1-R11 about the allegation that Facility staff did not notify residents' physician about changes in residents' condition while in care. 10 of 11 residents denied the allegation and stated that whenever they have a change in their health and well-being, the staff does notify their physician about any changes in their condition. LPA observed in the Care Plan Report notes, dated 07/12/2023, that R1 declined to be evaluated for R1’s annual RCFE medical exam. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not notify residents' physician about changes in residents' condition while in care. 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 # 2- Facility staff intimidated resident while in care. The details of the complaint alleged that the administrator (S1) and security staff provoked and created false information against R1 which resulted in R1 having aggressive and suicidal thoughts. On 03/28/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R11) regarding the allegation. 4 of 4 staff denied the allegation that Facility staff intimidated resident while in care. All staff (S1-S4) stated that they have never intimidated or retaliated against R1 while R1 was a resident in care that caused R1 to be in distress. All staff stated further, that R1 was the one that would make staff and residents uncomfortable with R1’s combative and aggressive behavior. S2 stated that R1 was issued several codes of conduct violations for R1’s behavior towards staff and residents; and was involved in several interdisciplinary meetings to bring attention to R1’s behavior but it persisted and didn’t get any better. But at no time did anyone ever intimidate R1. LPA interviewed R1-R11 about the allegation that Facility staff intimidated resident while in care. 10 of 11 residents denied the allegation and stated that they have not had any problems with staff intimidating or making them feel uncomfortable in any way. Report continued on LIC9099-C Based on interviews, there is insufficient evidence to support the allegation that the Facility staff intimidated resident while in care. 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 . No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Teresa Starks, Deputy Administrator.