Complaint·September 19, 2023

In regards to the allegation "Resident sustained bruises while in care" it was alleged that due to staff not evicting R1, R1 attacked R2 in their room leaving behind bruises. (5) of (5) Staff interviewed denied the allegation. (2) of (5) Residents interviewed stated that the facility should have evicted R1 prior to any physical violence occurring. (3) of (5) Residents interviewed were not able to corroborate the allegation. File review shows that on 9/3/22 , R1 had gone to R2's room and assaulted them physically without warning. Local law enforcement was contacted and did arrive but R1 was not arrested. Interviews with staff show that there was not enough sufficient documentation and reasoning to evict R1 from the facility prior to this incident as doing so would break Title 22 Regulations and could be seen as an illegal eviction. There were attempts communicated to LPA regarding R1 refusing to seek physical and mental revaluations to identify whether a higher level of care was needed. Ultimately, R1 did receive an eviction notice from the facility on 9/19/22 with supportive documentation of recurring rule breaking. Based on LPA's observations and interviews; 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. In regards to the allegation "Staff do not appropriately manage residents behavior" it was alleged that staff do not do anything regarding R1's behavior. (5) of (5) Staff interviewed denied the allegation. (3) of (5) Residents interviewed could not corroborate the allegation. Interviews with staff shows that R1 has been refusing assistance with seeing a doctor or having a re-evaluation done by staff. Due to the nature of maintaining privacy, other residents of the facility were not informed of what steps the facility was taking to ensure R1's behavior was addressed. From interviews with staff, it was believed that R1 needed to be evaluated as they may have needed a higher level of care but R1 refused. Interviews with staff also showed a plan to be vigilant of R1 in the common areas around other residents was communicated so that conflicts or disturbances to other residents involving R1 would be quickly addressed. There was no plan in place to provide 1 on 1 supervision. S1 updated LPA that Department of mental health arrived to visit R1 on 10/2/22 but they could not assist as R1 did not meet their criteria. Last needs and services plan was dated 10/3/22. R1 moved out on 10/20/22. Based on interviews and file review the facility was able to show that R1's behavior was being addressed. Based on LPA's observations and interviews; 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 and a copy of this report was provided