complaint·August 27, 2024

On 05/29/24, LPA Rios interviewed a Registered Nurse (RN) who is part of the Assisted Living Waiver Program (ALW) team, familiar with R1's placement. On 08/27/24 LPA interviewed R1's assigned Public Guardian (PG) at the time. A review of R1's record shows R1 was admitted to this facility on 09/24/21. According to the interview with R1’s PG they confirmed R1 has had periods where they have been admitted to skilled nursing facilities, hospitals and rehabilitation centers due to R1’s behavior at this facility. PG’s interview revealed the facility has always held a bed for R1 while waiting for R1’s discharge during those periods. On 06/12/24, the facility provided to the Community Care Licensing Department (CCLD) information regarding their efforts to transfer R1 to another facility. According to the information provided on January 2024 the administrator notified ALW nurse of R1’s change in behavior and requested assistance with finding another placement that could provide the required level of care. On 03/18/24 the administrator contacted R1’s PG notifying that the resident required a higher level of care and needed to be transferred. The interview with PG on 08/27/24, confirms they received a request on 03/18/24 for a transfer and they completed and returned the requested document. On 05/16/24 facility administrator coordinated an assessment with another facility, but the assessment resulted in a failed admission. Interviews with two (2) staff and the administrator on 05/29/24, revealed R1 will wander into other resident’s bedrooms and have heard other residents complain about R1’s behavior entering rooms without permission. Staff have also heard residents complain about R1’s yelling in the hallways repeating the same statements. Interview with nine (9) out of thirteen (13) residents who were interviewed for this allegation also corroborate witnessing R1 wander into their rooms or other rooms and yelling in the hallways. Interview with administrator revealed R1 has been known to display these behaviors when they need a medication adjustment. LPA attempted to interview R1, but R1 did not respond to questioning. One (1) staff revealed they witnessed a resident #2 (R2) push R1 causing R1 to fall down to the floor. Staff explained that R1 was grabbing R2’s plate. Another staff witnessed the same resident R2 grab R1 and return R1 to R1’s room. Staff and residents interviewed also reported seeing R1 with a bruise on their face recently prior to LPA's visit. LPA's observation of R1's face on 05/29/24 did not reveal a bruise. Staff and administrator interviewed report not witnessing how R1 got a bruise but that it could have been an un-witnessed fall. (Page 2 of 3) Review of ALW Individual Service Plan dated 12/03/22 to 06/03/23 revealed R1 has a risk of falls and is at risk of injury due to diagnosis. Physician's Report with exam date 12/16/24 notes client is non ambulatory and list motor impairment as muscle weakness. Six (6) out of the thirteen (13) residents interviewed on 05/29/24 corroborate witnessing resident’s yell, push or hit R1 when R1 is exhibiting a behavior. Resident's did not provide specific dates. LPA could not determine how long R1 has been exhibiting behaviors, however interviews with staff and residents indicate R1's behaviors where increasing and not stabilizing and other residents had already displayed increasing aggressive behavior towards R1. LPA's review of unusual incident reports revealed R1 had been sent out of the facility for different reason such as, confusion, not feeling well and dementia behavior. LPA could not find written documentation on actions or plans taken when R1 returned to the facility. According to interviews with the administrator and two (2) staff they were directed to keep a close eye on R1 and to follow R1 whenever possible. Staff also kept R1 in the medication room with them by offering R1 cookies and whenever possible the administrator would keep R1 in the administrator’s office. Interview with administrator on 08/27/24, revealed a written plan to address R1’s changed behaviors was not created after they notified ALW nurse on January 2024 that R1 had a change in behavior. According to the administrator the facility had a one on one for R1, but nothing documented on paper for this change. Information provided by the facility and the ALW nurse confirms they believed R1 required a higher level of care that the facility could not provide. Review of R1’s updated (no date recorded) Appraisal/Needs and Services Plan reveled facility did not document R1’s behavior of R1 wandering into other residents’ bedrooms, R1 yelling in the hallways, or R1’s tendency to grab other residents’ meal trays. On on 05/29/24 LPA could not find documentation the facility had developed a plan to assist R1 while they waited for R1’s possible transfer and that staff actions did not adequately provide R1 with a safe environment. Therefore, based on record review and interviews the allegation is deemed Substantiate at this time. Deficiencies cited (refer to LIC9099-D). Exit interview conducted. Appeals rights provided. Copy of report provided.