complaint·August 11, 2023

During the subsequent visit on 11/07/2022, LPA Baptiste obtained a copy of Staff roster, Resident roster, R1 unusual incident report dated 4/01/22 and 6/12/22, 9099 dated 4/14/2022, R2 admissions agreement, R2 Identification and emergency information, physicians report, and R2 appraisal. LPA Baptiste conducted a tour of the resident bedrooms/bathrooms in rooms 109,121,124,208,226,230. LPA interviewed Operations manager and Staff # S1 and S2. LPA interviewed service coordinator(S3) and residents# R3 through R8. The investigation reveals the following: Regarding " Resident sustained a bruise while in care.", This allegation was investigated on 4/14/2023 and was unsubstantiated. According to the investigation staff noticed residents were intoxicated and R1 had a bump on their forehead. Staff called paramedics and assisted R1 and R14. Interviews do not show lack of supervision as residents were in private behind closed doors. There are no existing laws or regulations that prevent residents from eating or drinking what they please. R1 stated to not have been made to do something against their will. Review of R1 and R14's file does not show limitation on what they are able to eat or drink. R1's file does not show that they need a certain amount of supervision from staff. Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported allegation. 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. Please see complaint # 28-AS-20220407162336 for further information. The investigation reveals the following: Regarding “Facility is not maintained clean and sanitary.", it is alleged that the resident’s bedrooms are unsanitary and residents shower contains mildew. During the tour of the facility, LPA did not observe mildew in the resident bathrooms nor any unsanitary living conditions. The Operations Manager denied the allegation stating the rooms are cleaned on a weekly basis. 3 out of 3 staff denied the allegation stating they have not seen mildew in the facility. 6 out of 6 residents interviewed denied the allegations stating their bedrooms and bathrooms are cleaned every day. The investigation reveals the following: regarding " Resident inappropriately touched other residents.", it is alleged that R3 inappropriately touched residents. Per IB’s investigation there are no witnesses who saw R3 attempt to grab resident R1 in the facility elevator. Since R3 denied doing so, we do not have any concrete basis to conclude it occurred. Regarding the incident between R2 and R3, per IB investigator R2 stated they consented to the sexual encounters with R3. Based on LPA's interviews, investigation revealed: 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. Exit interview conducted with Business Office Manager Joshua Oliver and a copy of this record provided. The investigation reveals the following: Regarding the allegation “Staff did not properly supervise a resident in care”, During IB’s investigation Resident #2 was found to have had several sexual encounters with Resident #3. Resident #3 was noted to have touched Resident #2 in a sexual manner on at least three separate occasions. These incidents were separately and individually reported to the facility receptionist by a facility staff member, a Resident, and a Resident’s Responsible Party. Resident#2 stated they consented to the encounters with R#3. Due to Resident #2 medical diagnosis Resident #2 may lack the capacity to give consent. However, even if Resident #2 had the capacity to consent, the facility was still negligent as nothing was done to verify resident #2 capacity. The facility did not address the first two incidents between Resident #2 and Resident #3 for the following reasons: Either Staff #4 failed to report the incidents to the Administrator, or The Administrator decided not to investigate the matter. IB Substantiated on Neglect/Lack of supervision due to the facility failing to establish Resident#2 capacity for consent. Based on observation, interviews and file review, the preponderance of evidence standard has been met, therefore, the above allegations is found to be SUBSTANTIATED. Exit Interview Conducted with Administrator Michael Forsgren / Appeal Rights Provided / A Copy of the Report Issued.