complaint·May 15, 2024

Interview with the former ED revealed it was reported that R2 bumped into R1, but the former ED never witnessed it. The former ED stated the facility was aware of R2’s aggressive behavior. The former ED spoke to R2 about the behavior and sent emails to staff to “keep an eye on" R2, but R2’s plan of care was not updated. Record review of R2’s physician’s report revealed R2 had aggressive behaviors and a diagnosis of dementia. Interview with S1 revealed R2 hit S1 with their walker when they got upset. S1 confirmed that the former ED sent staff an email on how to address the behavior, but staff did not receive a formal training. Interview with R2 at 10:20 a.m. on 11/01/2024 revealed they had never hit anyone. Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed they witnessed R2 hit S1. Interview with Staff #3 (S3) at 3:15 p.m. on 11/01/23 revealed they had been hit by R2 as well, and the former ED did nothing about it. Interview with the current ED revealed the facility updated R2’s plan of care i January of 2024 and trained staff at the same time. Based on interviews and record review, the facility did not prevent R2 from hitting others. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page and cleared due to prior corrective action. No immediate health and safety risks were observed. Exit interview conducted. Appeal rights discussed. Copy of report provided. Interview with the former ED revealed R1’s money was voluntarily placed in a trust account known as Resident Fund Management Service (RFMS).Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed residents can access their funds by making a request. After the request, the funds get disbursed in the form of cash a day later. S2 stated they explained this process to R1 while enrolling. S2 stated R1 eventually received their money but R1 did not agree on the amount received. Interview with R1 confirmed they received funds from the account but did not agree that the amount received was correct. Record review at 11:00 a.m. on 11/01/2023 revealed the facility provided all available funds to R1 after rent was paid. Based on interviews and record review, the facility did not mismanage resident funds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not prevent resident from engaging in inappropriate behaviors” it was alleged Resident #2 (R2) stalked Resident #3 (R3). Interview with R2 at 10:20 a.m. on 11/01/23 revealed they never stalked anyone. Interview with R3 at 12:40 p.m. on 11/01/23 revealed they were not stalked by anyone. Interviews with five (05) out of five (05) staff and four (04) other residents on 11/01/23 revealed they had no knowledge or reports of residents stalking or being stalked. Based on interviews, no residents were stalking or being stalked. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are not meeting resident's medical needs” it was alleged R1 had cellulitis on both feet and a scratch on their leg which was not properly cared for. Interview with the former ED revealed the facility nurse and home health attempted to check R1’s leg and feet. R1 refused help and requested their personal doctor instead. Additionally, R1 used to walk around the facility barefoot, so the former ED bought two (02) pairs of slippers for them to wear. Interview with R1 revealed the facility properly cared for the scratch on their leg. R1 received an antibiotic to reduce an infection. R1 also confirmed the former ED bought them slippers for their feet and ordered home health visits three (03) times per week to heal the wounds on their feet. R1’s physician told them their cellulitis was cured, but R1 disagreed and applied for a different home health agency. R1 believed their cellulitis was finally resolved after visits from the home health agency they had chosen. Based on interviews, the facility properly addressed R1’s medical needs in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.