complaint·October 12, 2021

Interviews with R#1, R#3, & R#5, could not understand what LPA Soto was asking and kept looking away from LPA Soto. Interviews with R#2 & R#4, stated that staff has never been rough with them or never seen any staff be rough with other residents. Interviews conducted do not concur with the above allegation. Allegation 2 - Facility staff did not prevent resident's from engaging in an altercation. Interviews conducted with Jessica, Director of Health Services, she stated that they did have 2 residents get into an altercation. She sent in the SIR. Residents fighting is very unusual, the 2 residents were separated immediately and redirected. They did not sustain any injuries. Interviews with S#2 – S#6, stated that they have never seen residents get into any altercations. Interviews with R#1, R#3, & R#5, could not understand what LPA Soto was asking and kept looking away from LPA Soto. Interviews with R#2 & R#4, stated that they have not seen residents fight. Interviews conducted do not concur with the above allegation. Allegation 3 - Facility staff are not ensuring that residents are dressed appropriately. Interviews conducted with Jessica, Director of Health Services, S#2 – S#6, stated that some of the residents have a behavior that they take their clothes and diapers off. They try to change the diaper themselves; they redirect the residents when that happens and try to let them know not to do that. They can’t remember, so they continue to do it. LPA Soto reviewed resident’s records and they show that some residents do have behaviors with taking their diaper and clothes off. The staff could not control what the residents will do, but the staff does redirected them as soon as they see the residents undressed or without diapers. Interviews with R#1, R#3, & R#5, could not understand what LPA Soto was asking and kept looking away from LPA Soto. Interviews with R#2 & R#4, stated that they have seen residents with no diapers and clothes, did not know who they were. Interviews conducted and records reviewed, do not concur with the above allegation. Allegation 4 - Staff is insufficient to meet resident's needs. Interviews conducted with Jessica, Director of Health Services, she stated that they have enough staff to cover all shifts. They are trying to see if more staff is needed, but they are not definite on them hiring extra staff. LPA Soto reviewed records and the facility does have enough staff for all shifts. Interviews with S#2 – S#6 and R#1 – R#6, They all stated that they feel and/or believe there are enough staff to take care of the resident’s needs. Interviews conducted and records reviewed, do not concur with the above allegation. Although the allegation 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 An exit interview was conducted with Jessica Ponce, Health Services Director, and a hard copy was provided.